BHA FPX 4006 Assessment 2: Compliance Program Implementation and Ethical Decision Making

Upcoding

One of the most prevalent kinds of billing frauds is called ‘upcoding’, which means the intentional attempt to apply incorrectly labelled billing codes with the purpose of signaling that more costly services have been provided than have probably been executed. The intention of such practice is to enhance payment for products and services resulting from assorted government programs like Medicare. Upcoding can become a financial problem in the healthcare system as explained by Hilal et al , (2021) who said that 19 is a potential financial threat to the healthcare system. BHA FPX 4006 Assessment 2 coding is utilized in 5 percent of reimbursement claims and, depending on the situation, Medicare spends about $300 per incident. The CMS is more interested in how serious this phenomenon is and how much it costs. For example, a healthcare provider offers a counseling session for 15 minutes but codes for 60 minutes of providing this service, hence the healthcare provider will gain more payment than the deserved amount (Dehnavi et al. , 2021).

Kickbacks

 Healthcare abuse means a situation in which there is misuse of the health sector and of the elements that are contained in the health sector; kickbacks are one of the sorts of healthcare abuse whereby providers are compensated in terms of monetary rewards by other parties in the healthcare sector based on an understanding that they will recommend that certain patients be admitted or that certain medicines or specific modes of treatment be ordered by them (Bosley, 2024). This practice mainly centers on the financial aspect as a way of benefiting the practice and not the benefit of the patient; therefore, patients may be subjected to certain treatments or prescriptions that may not be essential. For instance, a case where pharma firm is involved in bribery and offers unlawful remunerations to the healthcare provider enabling the firm to prescribe a certain high or low medication to the patient (CMI, 2021).

BHA FPX 4006 Assessment 2 HealthCare Faceilties

This structure creates a conflict of interest that financially rewards the provider for treatment choices; in essence, danger to the patient because the providers offer treatments that are not in that patient’s best interest. Such policies disrupt the level of trust that the patients have in their health care providers and may spew negative impacts to the concerned health care facilities. Because of the aforementioned segmented unethical practices, the government enacted the Anti-Kickback Statute side by side with Stark Law. The Anti-Kickback Statute prohibits providing and receiving a benefit to secure the referral of businesses to entities that are part of federal health care programs; therefore, such providers cannot receive any thing of value for the referral of clients. Known as the Physician Self-Referral Law or the Stark Law, this set of rules makes self-referral by a physician to settings where he/she can economically gain unlawful, if it does not fall under the law’s exemptions. Such laws aim at safeguarding the best interest of every individual in need of healers’ services, they do not allow funds that accompany these enticements to corrupt the system (Bosley, 2024).

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Medical Theft Identity

Fraud in connection with the provision of health care is now a very large problem, and impersonal, in terms of identification by a referring number, means that one person uses the number of another person in order to obtain health care services. Such kind of identity theft can result in grave implications for the individuals, as well as their medical records, and in severe monetary losses on all levels of the icles corresponding to several tiers of the healthcare system (Lopatina et al. , 2021). In the Federal and State Governments once again, the sources demonstrated that it is important not only to recognize medical identity theft with reference to the health of patients and healthcare organizations. For instance, in a study conducted by Jennings, (2022) the writer highlights a case where a person impersonated another person and went for a surgery – an example of actual apostle of this kind of fraud.

1.

False Claims Act

The False Claims Act was created under the U. S Department of Justice to cover fraud especially the billing practices and reimbursement claims thereby deriving revenues from the government Treasure (US Department of Justice, 2024). It relates to the untruthfulness in various parts of the healthcare sector; billing of wrong kind of health services, overcharging on surgeries with aim to gain higher reimbursement or wrong prices disclosing by firms regarding their supplied drugs.

FCA is a law that seeks to pin down people legally for geopolitical activities and make them bear the consequences of any heartless actions they have unleashed on the government. Consequently, it had the major focus of eradicating the fraud against the governmental plans and recover the amount to uphold the credibility of the system. Also, the FCA reduces fraud incidences by urging the whistleblower report the fraud when it is just beginning to ensure that there are few cases of fraud (US Department of Justice, 2024).

2.

Anti-Kickback Statute

BHA FPX 4006 Assessment 2 AKS stands for Anti-Kickback Statute that is a federal law which prohibits offering of or making payment for referrals for furnishing of medically unnecessary services to the patients. BHA FPX 4006 Assessment 2 Physicians provide costly medicines to patient with the aim to wrongly receive benefits from Drug Companies. AKSs are structures intended to safeguard patients whereas ensuring that the clinical decision-making processes remain sacred. For these violations, penalties and criminal charges may be charged on individuals who violated the AKS (US Department of Justice, 2024).

The legiteminate relations are prohibited between the health care providers and other persons through the application of the AKS. In that case, it is unlawful to offer and solicit for payments for the referral and purchasing of medical equipments and drugs. To proceed towards building a safety culture among staking its future on different players in the healthcare industry, it is necessary to underscore why the AKS frowns at kickbacks and self-referral arrangements.

3.

Stark Law/ Physician Self-Referral Law,

The Stark Law is a federal law in the United States which prohibits members in the health care sector from referring patients to programs reimbursed under the government’s familiarity such as Medicare to facilities where the member, or a close relative, has a financial interest (CMS, 2020). The one main goal of this law was to attempt to eliminate any situations where a patient is referred to a specific facility, hospital, or center due to money, not medical need. The civil remedies that have been provided for noncompliance include monetary modifications and possibilities of the exclusion from Medicare and Medicaid activities (CMS, 2020).

The Stark Law oversees the functioning of the healthcare system more concentrated on the patient’s welfare instead of compensating the providers (CMS, 2020). As one of the objectives of the anti-self-referral law, fraud control aims at the eradication of instances of self-referral schemes based on monetary motivation as well as reduction of redundant practices in healthcare with the view of boosting quality of patient care. This way, the law contributes to the elimination of any desire to make certain decisions in the medical field based on the profits that can be obtained instead of focusing on the patient’s genuine needs This way, rightful and ethical approaches are promoted in healthcare throughout the assistance of the law (CMS, 2020).

4.

Criminal Healthcare Fraud Statute

The Stark Law was designed to regulate the operations of the healthcare delivery system that is more focused on a patient’s need, not on the reimbursement for providers (CMS, 2020). The second goal of the anti-self-referral law is designed to curb fraud schemes that are motivated on the basis of monetary relations towards self-referral and to achieve the elimination of inessential procedures affecting the quality of health care with the intention of enhancing the quality of patient care. Thus, the law helps decrease the interest and ability to make some decisions in the sphere of medicine to receive a share of the profit instead of the patient’s actual needs For this way, rightful and ethical approaches are promoted during the assistance of the law in healthcare (CMS, 2020).

BHA FPX 4006 Assessment 2 Criminal Healthcare Fraud Statute is relevant for the health care system because it provides an example of the unlawful activity in the healthcare medical practice. By this law, healthcare professionals are shielded from engaging themselves in organized scheming to fraud the Medicare Program and hence it emphasizes the protection of the healthcare system. In this regard, its application helps in safeguarding the deployment of taxpayers’ money and defending the purity of health-care services delivery (McMurray & Smith, 2021).

Compliance Training: BHA FPX 4006 Assessment 2 Ensuring that first, periodic and second, extensive compliance programs are provided to the healthcare professionals are crucial to increasing ethical practices within health care facilities. This training concerns a training of staffs on how to perform coding and billing by the laid policies and procedures. By making sure that the service providers are knowledgeable in the current policies in coding, the compliance training aids in avoiding the consequences of upcoding as a result of negligence.

(Consulting, 2024)

 Training and Education for Staff: Conduct general meetings for the healthcare practitioners and the medication billing employees to deduce specific instructions on coding and documentation. Arrange seminars from time to time to remind the employees of the general and particular guidelines on coding. Consequently, after clinical coding consciousness-raising sessions, the relevant members of healthcare stated increased appropriateness of documentation of patient contacts and coding, as well as a decreased number of upcoding cases.

 (Bhati et al., 2023)

 Utilization of Technology for Detection: Use modern technological solutions, for example, billing software that has an auditing function to fight upcoding. Install process monitoring that alerts management about any billing problems as soon as they occur. When using data analytics tools there was detected a number of bill codes that showed certain atypical picture, which led to the identification of upcoding schemes.

(Hilal et al., 2021)

Regular Audits and Monitoring: Periodically scan through the billing records in an aim at identifying signs of upcoding. Carry out analytical analysis on billing codes in order to look for suspicious patterns of overbilling. In particular, it will be required to put in place constant control measures to ascertain that the assigned codes adhere to the right guidelines. This case emerged from a normal audit exercise whereby there was a mismatch of billed services and patients’ encounters. A closer look at SNF billing for services provided to patients with a CIMx indicated that there was upcoding, evidently by coding higher- level Medicare billing code of a service that did not meet the criteria entailing such billing code.

(Lin & Pantano, 2023)