Write a workplace brief (8-10 double-spaced pages) of evidence-based recommendations to identify and address upcoding, an incorrect health care billing practice. Include a description of the major categories of health care fraud and abuse and the laws des
Description
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 (24 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 (24 pages)
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.
Tip: Visit these websites:
Centers for Medicare and Medicaid Services. (2017). Avoiding medicare fraud and abuse: A
roadmap for physicians. Retrieved from https://www.cms.gov/Outreach-and-
Education/Medicare-Learning-Network-
MLN/MLNProducts/Downloads/Avoiding_Medicare_FandA_Physicians_FactSheet_905645.pdf
United States Department of Health and Human Services & Office of Inspector General.
(n.d.). Compliance education materials: Compliance 101. Retrieved from
https://oig.hhs.gov/compliance/101/
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 810 double-spaced content pages in Times New Roman, 12-point font, including the
reference page.
Title page: Develop a descriptive title of approximately 515 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.
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References:
Nursing Standards
Nursing and Midwifery Board of Australia. (2018). Code of conduct for midwives. https://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-standards.aspx
Clinical Guidelines
Guideline Adaption Committee. (2016). Clinical practice guidelines and principles of care for people with dementia. NHMRC Partnership Centre for Dealing with Cognitive and Related Function Decline in Older People. https://cdpc.sydney.edu.au/wp-content/uploads/2019/06/CDPC-Dementia-Guidelines_WEB.pdf
Living Guideline
Stroke Foundation. (2022). Australian and New Zealand living clinical guidelines for stroke management – chapter 1 of 8: Pre-hospital care. https://app.magicapp.org/#/guideline/NnV76E
Evidence-based practice
BMJ Best Practice
Goldfarb, S., & Josephson, M. (2020). Cystic fibrosis. BMJ Best Practice. https://bestpractice.bmj.com/
Schub, T., & Cabrera, G. (2018). Bites: Head lice [Evidence-based care sheet]. Cinahl Information Systems. https://www.ebscohost.com
Beyea, S. C., & Slattery, M. J. (2006). Evidence-based practice in nursing: A guide to successful implementation. http://www.hcmarketplace.com/supplemental/3737_browse.pdf
JBI: Evidence summary
Swe, K. K. (2022). Blood glucose levels: Self-monitoring [Evidence summary]. JBI EBP Database. https://jbi.global
JBI: Best practice information sheet
Bellman, S. (2022). Experiences of living with juvenile idiopathic arthritis [Best practice information sheet]. JBI EBP Database, 24(1), 1-4.
Cochrane Database of Systematic Reviews
Srijithesh, P. R., Aghoram, R., Goel, A., & Dhanya, J. (2019). Positional therapy for obstructive sleep apnoea. Cochrane Database of Systematic Reviews. https://doi.org/10.1002/14651858.CD010990.pub2
Drug Information
Codeine. (2023, January). In Australian medicines handbook. Retrieved February 2, 2023, from https://amhonline.amh.net.au
Colorado State University. (2011). Why assign WID tasks? http://wac.colostate.edu/intro/com6a1.cfm
Dartmouth Writing Program. (2005). Writing in the social sciences. http://www.dartmouth.edu/~writing/materials/student/soc_sciences/write.shtml
Rutherford, M. (2008). Standardized nursing language: What does it mean for nursing practice? [Abstract]. Online Journal of Issues in Nursing, 13(1). http://ojin.nursingworld.org/MainMenuCategories/ThePracticeofProfessionalNursing/Health-IT/StandardizedNursingLanguage.html
Wagner, D. (n.d.). Why writing matters in nursing. https://www.svsu.edu/nursing/programs/bsn/programrequirements/whywritingmatters/
Writing in nursing: Examples. (n.d.). http://www.technorhetoric.net/7.2/sectionone/inman/examples.html
Perth Children’s Hospital. (2022, April). Appendicitis [Emergency Department Guidelines]. Child and Adolescent Health Service. https://www.pch.health.wa.gov.au/For-health-professionals/Emergency-Department-Guidelines/Appendicitis
Department of Health. (n.d.). Who is being active in Western Australia? https://ww2.health.wa.gov.au/Articles/U_Z/Who-is-being-active-in-Western-Australia
Donaldson, L. (Ed.). (2017, May 1). Healthier, fairer, safer: The global health journey 2007-2017. World Health Organisation. https://www.who.int/publications/i/item/9789241512367
NCBI Bookshelf
Rodriguez Ziccardi, M., Goyal, G., & Maani, C. V. (2020, August 10). Atrial flutter. In Statpearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK540985/
Royal Perth Hospital. (2016). Procedural management: Pre and post (24-48 hours) NPS. Canvas. https://courses.ecu.edu.au
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