Now that you are familiar with coding systems and practices involved in renderin

Now that you are familiar with coding systems and practices involved in rendering care, let’s think about potential risks involved in coding and documenting care. Review the following Medicare Learning Network publication that describes healthcare fraud and abuse.
MEDICARE FRAUD & ABUSE: PREVENT, DETECT, REPORT
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Fraud-Abuse-MLN4649244.pdf
Services Not Rendered: The submission of a claim for health care services, treatments, diagnostic tests, medical devices, or pharmaceuticals that were never rendered.
Ghost Patients: The submission of a claim for health care services, treatments, diagnostic tests, medical devices, or pharmaceuticals provided to a patient who either does not exist or who never received the service or item billed for in the claim.
Up-Coding Services: Billing of government and private insurance programs is done using a complex series of numerical codes that identify the specific procedure or service being performed. These code sets can include: the American Medical Association’s Current Procedural Terminology (“CPT”) codes; Evaluation and Management (“E&M”) codes; Healthcare Common Procedure Coding System (“HCPCS”) codes; and International Classification of Disease (“ICD-9”) codes. Government health care programs assign a dollar amount it will pay for each procedure code. Up-coding occurs when a health care provider submits of a claim for health care services, treatments, diagnostic tests, or items that represent a more serious and more expensive procedure than that which actually was performed. Up-coding can be a violation of the Federal False Claims Act.
Lack of Medical Necessity: In order to qualify for payment by government health care programs, health care services, treatments, diagnostic tests, medical devices, and pharmaceuticals must be medically necessary. Health care providers are required by law to document the medical necessity of the treatment or services for which they are seeking reimbursement. One common type of fraud has been to submit claims for services, treatments, diagnostic tests, and medical devices that are not medically necessary.
False Certification: When physicians, hospitals, and other health care providers submit bills to government health care programs they are required to include a number of important certifications, including that the services were medically necessary, were actually performed, and were performed in accordance with all applicable rules and regulations
25 points total.
Select one category of fraud or abuse, either from the Medicare Learning Network publication or from the list above.
Describe an example of a coding or documentation related practice, situation or event that might contribute to an occurrence of this fraud or abuse category. (5 points)
Explain how this undesirable outcome meets the definition of this fraud or abuse category. (5 points)
Compose a recommendation, control, or best practice that is designed to reduce the likelihood of this type of fraud or abuse violation. Include implementation steps and any departments or work groups that might be involved. (15 points)