Identifying and Addressing Upcoding Template Major Categories of Health Care Fraud and Abuse Category of Health Care Fraud andAbuse

Identifying and Addressing Upcoding Template Major Categories of Health Care Fraud and Abuse Category of Health Care Fraud andAbuse

Description of Category and Example from Authoritative Source*

Charity is helping another person when the receiver does not expect to be enabled in return.Despite the hopeless prognosis, a few highly trained medical professionals have persisted in providing therapy. Because of this, taking advantage of the people you are supposed to be helping is unethical, even if doing so may result in financial gain (Timofeyev,2020). For example, it would be unethical in the field of audiology to supply a patient with hearing aids if an audiogram revealed that the patient would not benefit much from amplification. This would be an example of an unethical practice. Control over service fees by those receiving the servicesIn environments where students pay for the services they get, the needs of the students must be adequately articulated in the criteria given by payers. Under the correct circumstances, students may be able to bill Medicare Part A for their services. On the other hand, a qualified professional is necessary to get payments from Medicare Part B, and they are now allowed to employ student assistance. For this reason, it is essential to determine the appropriate level of supervision for a student. It is reasonable to anticipate that the supervising physician will consider all of the ASHA guidelines, the requirements of applicable state laws, and the circumstances of appropriate payer coverage (Rao, 2020). Employees are expected to work longer and more complex than is required.It is immoral for managers to expect or order their workers to provide more services than are necessary for a given financial situation, whether acute rehabilitation, home care, or long-term care. When patients enter a skilled nursing facility, they must undergo an evaluation and treatment plan, a kind of healthcare fraud and abuse. You falsely represent one's financial situation to get aid, compensation, or favors.Correct documentation of Medicare services is essential. Therefore, professionals must deliver treatments regardless of how the invoices will be submitted for financing or payment (Esposito,2020). This fraud involves professionals who give passable care but who, with the patient's knowledge, conceal important information about the treatment's 1

Remove or Replace: Header Is Not Doc Title Category of Health Care Fraud andAbuse Description of Category and Example from Authoritative Source* foundation. Medical choices are not always made in the patient's best interests. UpcodingUpcoding is another kind of healthcare fraud and abuse. Some dishonest doctors and hospitals will use it to charge Medicare more money than they earned. This suggests the provider receives payment from Medicare over what they are owed. In light of this, upcoding is illegal since it constitutes Medicare fraud, a violation of the F.C.A. To commit upcoding fraud, a provider would submit claims using CPT codes for more extensive care than was rendered. Let's pretend a doctor has just finished a quick operation on the patient's chest. When billing Medicare, they will utilize the CPT code for "open heart surgery." The doctor has been accused of upcoding fraud since the billing code for open-heart surgery is more profitable than the billing code for the more routine chest procedure. *Be sure to include the billing practice known as upcoding. 2

Remove or Replace: Header Is Not Doc Title Five Health Care Fraud and Abuse Laws NumberHealth Care Fraud andAbuse LawDescription of LawRationale: How Does This Law Apply to Health Care? 1.False Claims Act [31 U.S.C. § § 3729 - 3733]To prevent the selling of poor or overpriced federal government products or services to private persons and enterprises, the False Claims Act (F.C.A.) was enacted. Submittingfalse or erroneous Medicare claims is a criminal offense. One may face a punishmentof up to three times the amount of the program's loss, plus an extra $11,000 per fraudulent claim, if they are found in violation of the Fair Credit Reporting Act. The Act's penalties would quickly add up since each time a service is invoiced to Medicare, it would be deemed a claim.Upcoding will focus its attention on hospitals and other medical facilities that defraud insurance companies like Medicare by submitting claims for services that were never really rendered. The Patient Protection and Affordable Care Act (ACA) will begin its rollout in the healthcare business with this particular subfield of the industry. For instance, a medical practitioner may submit a claim to a health insurance program that is supported by the government for a sum of money that is 3

Remove or Replace: Header Is Not Doc Title NumberHealth Care Fraud andAbuse LawDescription of LawRationale: How Does This Law Apply to Health Care? great