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  • Health care leaders must be familiar with laws, regulations, and the associated organizational policies and procedures that support compliance. Fraud and abuse is just one example of an important compliance area in health care administration. This is a complex legal subject; many helpful government resources, however, are available to enhance understanding of laws, regulations, and the steps to take when suspected or actual incidents occur.Other important legal considerations within health care fraud and abuse include the:
    • Federal False Claims Act.
    • Anti-Kickback Statute.
    • Physician Self-Referral Law.
    • Criminal Health Care Fraud Statute.
    • Exclusion Statute.
    • Civil Monetary Penalties Law.

    Some of these involve related or overlapping areas.This point in your health care administration career is an ideal time to deepen your knowledge of, and skills in, these fraud and abuse areas. You may wish to develop a short list of legal topics to assist in ongoing future monitoring workplace activities. It is important to include the associated authoritative governmental websites in your topic list.In this assessment, you will continue your team work for Vila Health’s Chief Compliance Officer. This time, you have been tasked with constructing a workplace brief for recommendations on identification of and interventions to address incorrect healthcare billing practices. In this case, upcoding is the incorrect billing practice that is the focus of the Chief Compliance Officer. Your workplace brief will be used to influence future policy and procedure content for billing practices, including the incorrect practice of upcoding.

    DEMONSTRATION OF PROFICIENCY

    By successfully completing this assessment, you will demonstrate your proficiency in the course competencies through the following assessment scoring guide criteria:

    • Competency 1: Analyze health care laws and regulations from a local, state, and federal level.
      • Describe major categories of health care fraud and abuse, including the billing practice known as upcoding.
    • Competency 3: Assess the importance of continuous readiness in the health care organization.
      • Propose a list of evidence-based recommendations based on information from the Office of the Inspector General to identify and address upcoding within a health care organization.
    • Competency 4: Explain how governing body and regulatory agency standards exercise oversight authority within a health care organizational setting.
      • Provide a synopsis of five laws relating to health care fraud and abuse.
      • Explain one law that pertains to the practice of upcoding.
    • Competency 5: Communicate in a manner that is scholarly, professional, and respectful of the diversity, dignity, and integrity of others and is consistent with health care professionals.
      • Develop a clear, concise, well-organized, and generally error-free workplace brief that provides evidence-based recommendations about how to identify and address the incorrect billing practice of upcoding.

    INSTRUCTIONS

    In this assessment you will continue as a member of the Chief Compliance Officer’s team. Recently, an incorrect billing practice known as upcoding has been discovered. Upcoding is a common area for fraud and abuse, and the recent incident has become an area of major focus for the Chief Compliance Officer.The Chief Compliance Officer has tasked you with researching and making evidence-based recommendations about how to identify and address this incorrect billing practice. Your recommendations will be considered for possible inclusion in future policy and procedure content.The Chief Compliance Officer has stressed with you the importance of incorporating evidence-based recommendations. This individual is specifically interested in the Office of the Inspector General’s position on upcoding, any relevant case precedents, and any available resources for health care organizations. You know from experience that the workplace brief will need to include substantiation of all facts and recommendations from authoritative sources. The team leader has asked you cover all of the following headings in your brief:

    Major Categories of Health Care Fraud and Abuse (2 pages)
    • Describe the major categories of health care fraud and abuse.
      • Be sure to include the billing practice known as upcoding.
    Five Health Care Fraud and Abuse Laws (3 pages)
    • Provide a synopsis of five laws relating to health care fraud and abuse.
    • Include the rationale for why you selected the laws you did.
    Upcoding and the Law (2–4 pages)
    • Explain in detail one law pertaining to upcoding.
      • Be sure to explain how the law specifically applies to upcoding.
    • Provide an actual example of upcoding.
      • Select your example from your suggested resources, from research you conducted on the topic, or from your professional experience. If your example stems from your professional experience, please be sure to protect individual and organizational identities.
    Identifying and Addressing Upcoding in Health Care (2–4 pages)
    • Propose a list of evidence-based recommendations to identify and address upcoding in the health care environment.

    ADDITIONAL REQUIREMENTS

    • Written communication: Use the linked Identifying and Addressing Upcoding Template [DOCX]. Ensure your workplace brief is clear, succinct, well-organized, and generally free of errors in grammar, punctuation, and spelling.
    • Length: Approximately 8–10 double-spaced content pages in Times New Roman, 12-point font, including the reference page.
    • Title page: Develop a descriptive title of approximately 5–15 words. It should stir interest, yet maintain professional decorum. Ensure that your title page conforms to current APA format.
    • References: Include a minimum of 6 current (within the past 5 years), authoritative citations in current APA format. Include a separate reference page that also conforms to APA guidelines.
    • APA format: Use current APA style and formatting. Indent the first sentence of all new paragraphs.
    • Font: Times New Roman, 12-point.
    • Scoring guide: Review the scoring guide for this assessment so that you understand how your faculty member is going to evaluate your work.
  • SCORING GUIDE

    Use the scoring guide to understand how your assessment will be evaluated.VIEW SCORING GUIDE

  • CRITERIA NON-PERFORMANCE BASIC PROFICIENT DISTINGUISHED
    Describe major categories of health care fraud and abuse, including the billing practice known as upcoding. Does not describe major categories of health care fraud and abuse, including the billing practice known as upcoding. Lists but does not describe major categories of health care fraud and abuse, including the billing practice known as upcoding. Omissions and/or errors exist. Describes major categories of health care fraud and abuse, including the billing practice known as upcoding. Analyzes major categories of health care fraud and abuse, including the billing practice known as upcoding. Analysis includes multiple examples, specifics, and references to current, authoritative sources, such as government websites.
    Propose a list of evidence-based recommendations based on information from the Office of the Inspector General to identify and address upcoding within a health care organization. Does not propose a list of evidence-based recommendations based on information from the Office of the Inspector General to identify and address upcoding within a health care organization. Proposes a list of recommendations to identify and address upcoding within a health care organization. Not all recommendations are evidence-based or based on information from the Office of the Inspector General. Omissions and/or errors exist. Proposes a list of evidence-based recommendations based on information from the Office of the Inspector General to identify and address upcoding within a health care organization. Proposes a list of multiple evidence-based recommendations based on information from the office of the Inspector General to identify and address upcoding within a health care organization. Recommendations include multiple examples, specifics, and references to current, authoritative sources, such as government websites.
    Provide a synopsis of five laws relating to health care fraud and abuse. Does not provide a synopsis of five laws relating to health care fraud and abuse. Provides a synopsis of five laws relating to health care fraud and abuse; however, omissions and/or errors exist. Provides a synopsis of five laws relating to health care fraud and abuse. Provides a succinct synopsis of five laws relating to health care fraud and abuse. Synopsis includes multiple examples, specifics, and references to current, authoritative sources, such as government websites.
    Explain one law that pertains to the practice of upcoding. Does not explain one law that pertains to the practice of upcoding. Attempts to explain one law that pertains to the practice of upcoding; however, omissions and/or errors exist. Explains one law that pertains to the practice of upcoding. Explains one law that pertains to the practice of upcoding. Explanation includes multiple case examples, specifics, and references to current, authoritative sources, such as government websites.
    Develop a clear, concise, organized, and generally error-free workplace brief that provides evidence-based recommendations about how to identify and address the incorrect billing practice of upcoding. Does not develop a clear, concise, organized, and generally error-free workplace brief that provides evidence-based recommendations about how to identify and address the incorrect billing practice of upcoding. Attempts to develop a clear, concise, organized, and generally error-free workplace brief that provides evidence-based recommendations about how to identify and address the incorrect billing practice of upcoding; however, significant lapses, omissions, and/or errors exist. Develops a clear, concise, organized, and generally error-free workplace brief that provides evidence-based recommendations about how to identify and address the incorrect billing practice of upcoding. Develops a clear, concise, organized, and error-free workplace brief that provides evidence-based recommendations about how to identify and address the incorrect billing practice of upcoding. Brief includes multiple case examples, specifics, and references to current, authoritative sources, such as government websites.

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