Fraud and Abuse: Incorrect Billing Practices

Fraud and Abuse: Incorrect Billing Practices

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 following laws and statutes:

Federal False Claims Act.
Anti-Kickback Statute.
Physician Self-Referral Law.
Criminal Health Care Fraud Statute.
Exclusion Statute.
Civil Monetary Penalties Law.

Explain in detail one law pertaining to upcoding.
Be sure to explain how the law specifically applies to upcoding.
Provide actual examples of upcoding.
Select your examples from the assigned readings, from research you conducted on the topic, or from your professional experience. If your examples stem from your professional experience, please be sure to protect individual and organizational identities.

Evidence-Based Recommendations to Address Upcoding

Propose a list of evidence-based recommendations to identify and address upcoding in the health care environment.
Be sure to consider in your recommendations what the Office of Inspector General has to say about identifying and addressing upcoding.


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