BHA FPX4006 Assessment 2 Identifying and Addressing Upcoding

BHA FPX4006 Assessment 2

Identifying and Addressing Upcoding 

Major Categories of Health Care Fraud and Abuse

Category of Health Care Fraud and Abuse

Description of Category: 

BHA FPX4006 Assessment 2 Identifying and Addressing Upcoding

Billing for unnecessary services

Performing and billing for services that are not medically necessary to increase a provider’s billing and reimbursement (CMS, 2021). An example would be performing a surgery when other non-invasive measures may have been as effective.

Upcoding/Improper coding

Incorrect billing which may include upcoding or not bundling certain codes. Using a higher Evaluation and Management (E/M) code than actually performed is upcoding. Unbundling would be billing two separate codes when one code would account for both of the other codes (CMS, 2021).

Kickback

A kickback would be receiving a gifts r rewards for patient referrals or any increase of business that would result in higher reimbursement (CMS, 2021). An example would be sending all surgeries to a specific doctor in exchange for use of that doctor’s vacation home.

Duplicate claims

When an organization bills multiple times for a service that was only performed once is duplicate billing (CMS, 2021). An example would be if a patient only visited the doctor one time but the insurance company was billed more than once.

Fraudulent billing

This would be when an organization bills for things that were never performed (CMS, 2021). An example would be if a patient was billed for a strep test but a strep test was never performed.

 

BHA FPX4006 Assessment 2 Identifying and Addressing Upcoding

Five Health Care Fraud and Abuse Laws

Number

Health Care Fraud and Abuse Law

Description of Law

Rationale:  How Does This Law Apply to Health Care?

1.

False Claims Act

The False Claims Act states it is illegal to submit claims for payment to Medicare or Medicaid that are known to be false or fraudulent. This protects the government form being overcharged (OIG, n.d.-a).

This law applies to healthcare because this is how health care organizations are remimbursed for Medicare/Medicaid services.

2.

Anti-Kickback Statute

The Anti-Kickback Statute is a criminal law regarding the willful payment to reward or increase patient referrals to increase business by billing federal healthcare programs (OIG, n.d.-a).

This applies to healthcare because it prevents physicians from receiving “bonuses” from a pharmaceutical company for promoting a medication.

3.

The Stark Law

The Stark Law states a healthcare professional may not refer to another physician or organization where they have financial ties (OIG, n.d.-a)

This applies to healthcare by preventing a doctor who owns a surgery center from sending all surgeries to that surgery center.

4.

The Exclusion Statute

The Exclusion statute allows the OIC to exclude those convicted of certain offenses from reimbursement/participation from federal healthcare programs, (CMS, 2021)

The Exclusion statute applies to healthcare as it is a consequence of violating several laws, including those previously discussed.

5.

Criminal Health Care Fraud Law

The Social Security Act includes the Criminal Health Care Fraud Statute. This penalizes “knowingly executing, or attempting to achieve, a scheme or lie in connection with the delivery of, payment for, healthcare benefits, items, or services to wither defraud a health care program or obtain profit from a healthcare program” (CMS, 2021).

This applies to healthcare by creating structure and making it illegal to defraud the government.BHA FPX4006 Assessment 2 Identifying and Addressing Upcoding

Upcoding and the Law

Law Pertaining to Upcoding

Explanation of Upcoding

Case Example of Upcoding

False Claims Act

Upcoding happens when charges are submitted to an insurance provider for a higher code than what was performed (CMS, 2021).

If a patient was only seen for a brief visit but was billed for a higher E/M code such as an intermediate visit.BHA FPX4006 Assessment 2 Identifying and Addressing Upcoding

 

Evidence-Based Recommendations to Address Upcoding

Recommendation*

Source

Create Written policies and procedures including what coders should do when presented with a situation not addressed in current coding literature. Review annually.

(Profit & Hamman (n.d.).

Periodic internal audits allow quick determining if upcoding has occurred.

(Nel, 2019).

Training physicians to chart and code accurately as well as the consequences of upcoding.

(Nel, 2019).

Use of professional billing and coding personnel. Ensuring properly educated individuals are coding will decrease potential upcoding incidents.

(Nel, 2019).

Be aware and understand your health system’s “hot targets”. Utilize the OIG’s annual work plan to model an annual risk assessment. BHA FPX4006 Assessment 2 Identifying and Addressing Upcoding

(OIG, n.d.-b)

 

References

CMS. (2021). Medicare Fraud & Abuse: Prevent, Detect, Report. CMS.gov. Retrieved from https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Avoiding_Medicare_FandA_Physicians_FactSheet_905645.pdf.

Nel, W. (2019). Upcoding Fraud Discovery in the Economical Fields Using Block Chain Technology. International Journal of

Innovative Technology and Exploring Engineering.

OIG. (n.d.-a). A Roadmap for New Physicians. US Department of Health and Human Services Office of Inspector General.

            https://oig.hhs.gov/compliance/physician-education.

 OIG. (n.d.-b). Fraud and Abuse Laws. US Department of Health and Human Services Office of Inspector General. 

            https://oig.hhs.gov/compliance/physician-education/fraud-abuse-laws/.

 Profit, S. & Hamman, C. (n.d.). Coding Compliance: Practical Strategies for Success. AHIMA HIM Body of Knowledge.

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