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BHA FPX 4006 Assessment 2
Identifying and Addressing Upcoding
Another predominant billing scam is termed as ‘upcoding’; this is deemed as an intentional action, where wrongly named billing codes are used to describe that a higher level of costly services was delivered when most probably not implemented.
The goal of this practice is to receive the maximum amount possible for products and services provided by multiple programs, including Medicare. It has been suggested that upcoding is a financial threat to the entire healthcare system, as commented by Hilal et al. (2021).
The Centers for Medicare & Medicaid Services (CMS) wishes to know how grave this problem is and the extent of the cost. For instance, a healthcare provider gives a counseling session of 15 minutes but codes the session to have taken 60 minutes and, therefore, will be paid more than what they are supposed to (Dehnavi et al., 2021).
Healthcare abuse means that there is a misuse of the health sector, and kickbacks are one of the sorts whereby other actors around the health sector pay providers in exchange for clients’ recommendations or recommendations for medicines or treatment procedures (Bosley, 2024).
This practice is mainly fueled by the need to make a profit and not the welfare of the patient, thus putting patients through treatments or prescriptions they may not require at all. For example, a case where a pharmaceutical company is found to have offered a healthcare provider certain unlawful extra rewards, low or high, to prescribe a particular drug to their patients (CMI, 2021).
BHA FPX 4006 Assessment 2 Compliance Program Implementation and Ethical Decision-Making
This structure makes the monetary incentives of the provider merge with the decisions about the treatment, meaning danger to the patient, for the provider prescribes the therapy that does not actually benefit them. Such policies reduce the confidence that the patients have in their healthcare providers and indirectly impact the medical facilities of concern that are part of federal healthcare programs; thus, it means that such providers should not receive any gifts for referring their patients.
Originally called the Physician Self-Referral Law or the Stark Law, this collection of rules makes the self-referral of a physician to a center that can financially profit from it unlawful unless it is an exception to the law. Such laws serve the purpose of safeguarding the best interest of each citizen who requires medical care, free from briberies, which accompany financial bonuses attached to such entitlements (Bosley, 2024).
Five Health Care Fraud and Abuse Laws
Fraud related to the healthcare sector is a significant problem, and medical identity theft is the case when one person uses a referring number belonging to another person to gain medical services. Such type of identity theft can produce very grievous outcomes for the victims, their medical information, and seniors in the healthcare systems, as well as tremendous fiscal losses in all the tiers of the healthcare system (Lopatina et al., 2021).
From the violations escalating out of both Federal and State Governments, it is pertinent to recognize medical identity theft in terms of patient and health, as well as healthcare organizations’ wellness. For instance, in Jennings (2022), the writer presented a case where a person stole another individual’s identity for surgery, which shows the practical application of this type of fraud.
The main goal of the False Claims Act approved under the United States Department of Justice is to identify fraud cases related to billing practices and reimbursement claims by obtaining a profit from the government’s money (US Department of Justice, 2024). It concerns the conduct of untruths in various parts of the healthcare system, billing themselves for wrong services, overcharging on surgeries with a view of securing higher reimbursement, or the wrong prices declared by drug firms for their products.
The FCA is a law that aims at legal consequences to be meted out on any independent that has acted in a remorseless manner to hurt the government by filing fake claims. Hence, its main aim is to minimize fraudulent practices against governmental programs and to recuperate the stolen amount to uphold the authenticity of the process.
Also, the FCA prevents fraud by motivating whistleblowers to report the fraud and, at the initial stage possible to avoid frequent cases of fraud (US Department of Justice, 2024). The Anti-Kickback Statute (AKS) is a federal law that penalizes the offering for or receipt of remuneration for the purpose of inducing referrals for the submission of claims for Medicare or Medicaid reimbursement for items or services that are not reasonable and necessary for the patient’s health.
The physicians provide costly medications to the patients with the motive of getting wrongful remuneration from the Drug Companies. AKS are intended for patient safekeeping and to preserve the confidentiality of medical decisions. Regarding such violations, penalties and criminal charges may be charged on individuals who violated the AKS (US Department of Justice, 2024).
Evidence-Based Recommendations to Address Upcoding
The AKS applies to the health care organization by invalidating illegitimate relations between health care providers and other persons. If so, both giving and receiving payments for arrangements of referrals for medical equipment and the purchase of medications is unlawful.
Compliance Training: Compliance training should be incorporated frequently and be broad in order to keep healthcare providers embodying ethical practices in healthcare facilities. This training is more about communicating to the staff the right approach that should be applied in coding and billing in line with the set standards. Thus, compliance training reduces the possibility of healthcare providers upcoding by passing the required updates on coding regulations to other providers.
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Training and Education for Staff: It is crucial to offer extensive educational seminars and workshops for healthcare professionals and the billing departments pertaining to the correct coding techniques as well as documentation protocol. Ensure the staff is updated with the detergent coding regulations and the various practices through refresher courses as often as possible.
In general, increased attention to the question of coding after having received training sessions on the principles of coding led to a decrease in rates of upcoding based on better identification of the patient’s encounter and corresponding coding rates assigned.
Utilization of Technology for Detection: Enhance the use of technology by purchasing audited billing software that can help in identifying and practicing up-coding. Businesses should incorporate automatic tracking of the billing processes so as to detect deviations as soon as they occur. A healthcare organization needed to use data analytics tools to recognize the irregularities in billing codes; as a result, it launched a deeper assessment that led to the upcoding schemes’ discovery.
Regular Audits and Monitoring: Schedule billing records checks to be done periodically because they will show tendencies of upcoding. Conduct billing code analysis in order to find discrepancies that hint at inward artificial syndication of bills.
It is necessary to establish continuous control measures to enable the organization to sustain compliance with coding rules. The breaches were discovered when there was a conflict between the charges previously issued and the record of patients’ meetings. Additional analysis showed that upcoding was also present; that is, using codes for higher levels of care when the service did not qualify for it.
Whistleblower Reward System: Another proposed measure for combating upcoding and violations of healthcare laws is the introduction of a system of rewards for whistleblowers. This system encourages employees to prosecute for fraud and upcoding issues, and no one can harm the whistleblower. Concerning such frauds, it is encouraged that whistleblowers report them directly to the management of the hospitals in question.
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BHA FPX 4006 Assessment 3 Compliance Training
References
Bhati, D., Deogade, M. S., & Kanyal, D. (2023). Improving patient outcomes through effective hospital administration: A comprehensive review. Cureus, 15(10).
https://doi.org/10.7759/cureus.47731
Bosley, S. (2024, February 6). What Are Kickbacks? TZ Legal – Fraud Fighters.
https://www.fraudfighters.net/news/what-are-kickbacks/
CMI. (2021). Pharmaceutical companies’ payments to healthcare professionals: an eclipse of global transparency. U4 Anti-Corruption Resource Centre.
https://www.u4.no/blog/pharmaceutical-payments-to-healthcare-professionals
CMS. (2020). CMS announces historic changes to physician self-referral regulations. Cms.gov.
Consulting, Y. H. (2024, February 27). Healthcare Compliance Training: Importance & Benefits of Training. Consulting, Inc.
Dehnavi, Z., Ayatollahi, H., Hemmat, M., & Abbasi, R. (2021). Upcoding Medicare: Are Healthcare fraud and abuse increasing? Perspectives in Health Information Management, 18(4), 1f.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8649706/
Drabiak, K., & Wolfson, J. (2020). What should healthcare organizations do to reduce billing fraud and abuse? American Medical Association Journal of Ethics, 22(3), 221–231.
https://doi.org/10.1001/amajethics.2020.221.
Ferry, J., & Medlin, L. E. (2022). The False Claims Act. Springer, 277–292.
https://doi.org/10.1007/978-3-031-08162-0_17
Geruso, M., & Layton, T. (2020). Upcoding: Evidence from Medicare on squishy risk adjustment. Journal of Political Economy, 128(3), 984–1026.
https://doi.org/10.1086/704756
Hilal, W., Gadsden, S. A., & Yawney, J. (2021). A Review of Anomaly Detection Techniques and Applications in Financial Fraud. Expert Systems with Applications, 193(1), 116429.
https://doi.org/10.1016/j.eswa.2021.116429
Jennings, W. (2022). Fraud Investigation and Forensic Accounting in the Real World.
https://doi.org/10.1201/9781003121558
Lin, J., & Pantano, J. (2023). Hospital Upcoding Decisions under Medicare Audits.
https://www.jianjinglin.com/uploads/9/0/8/4/90844182/cert.pdf
Lopatina, K., Dokuchaev, V. A., & Maklachkova, V. V. (2021, October 1). Data Risks Identification in Healthcare Sensor Networks. IEEE Xplore.
https://doi.org/10.1109/EMCTECH53459.2021.9619178
US Department of Justice. (2024, February 23). The False Claims Act. Justice.gov; U.S. Department of Justice.
https://www.justice.gov/civil/false-claims-act
Vian, T., Agnew, B., & McInnes, K. (2022). Whistleblowing as an anti-corruption strategy in health and pharmaceutical organizations in low- and middle-income countries: A scoping review. Global Health Action, 15(1).
