Describe the major categories of health care fraud and abuse

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Question description

GRADING RUBRIC MUST BE FOLLOWED

TEMPLATE MUST BE COMPLETED AS WELL

Write a workplace brief (5-7 single-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 designed to address them.

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 (1 page)
  • 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 (2 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 (1 to 2 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 (1 to 2 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/

Compare the statistics for a health concern of a vulnerable or diverse population to the statistics for the general population

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Question description

OVERVIEW

Prepare a 4–5-page review of recent research that examines statistics on the primary health concern of a population, describes the methods and tools used in the research studies, explains the factors that affect health promotion and disease prevention for a population, and recommends a health care initiative.

Note: The assessments in this course build upon each other, so you are strongly encouraged to complete them in sequence.

The ability to locate, evaluate, and apply research is an important skill for nurses to develop in order to provide evidence-based care for individuals, families, communities, and health care systems.

By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria:

  • Competency 1: Explain the principles and concepts of disease prevention and health promotion for diverse and vulnerable populations.
    • Compare the statistics for a health concern of a vulnerable or diverse population to the statistics for the general population.
    • Explain the factors that affect health promotion and disease prevention for a vulnerable or diverse population.
    • Recommend an evidence-based health care initiative for a specific health care concern of a vulnerable or diverse population.
  • Competency 3: Apply basic epidemiological concepts, data analysis methods, tools, and databases to determine the effectiveness of health promotion and disease prevention initiatives for diverse and vulnerable populations.
    • Describe the epidemiological concepts, data analysis methods, tools, and databases used in research studies related to health concerns for a vulnerable or diverse population.
    • Describe health care initiatives used by organizations to address the health care concerns of vulnerable or diverse populations.
  • Competency 5: Communicate in a manner that is scholarly, professional, and consistent with expectations for members of the health care professions.
    • Write content clearly and logically, with correct use of grammar, punctuation, and mechanics.
    • Correctly format paper, citations, and references using APA style.

    CONTEXT

    It is crucial for health educators to exemplify how health practitioners in general should communicate with different clients, demonstrating how to interact with racially and ethnically diverse populations in order to provide adequate health information that encourages clients to make decisions concerning their health and health care. As a provider, you must continually advocate for effective cross-cultural communication and remember to focus on the important elements of communication, cultural sensitivity, marketing techniques, and language barriers as you carry out your role and function in various environments (Pérez & Luquis, 2014).

    Reference

    Pérez, M. A., & Luquis, R. R. (2014). Cultural competence in health education and health promotion (2nd ed.). San Francisco, CA: Jossey-Bass.

SUGGESTED RESOURCES

Internet Resources

Access the following resources by clicking the links provided. Please note that URLs change frequently. Permissions for the following links have either been granted or deemed appropriate for educational use at the time of course publication.

  • U.S. Department of Health and Human Services, Office of Minority Health. (n.d.). The National CLAS Standards. Retrieved from http://minorityhealth.hhs.gov/omh/browse.aspx?lvl=…
  • U.S. Department of Health and Human Services, Office of Minority Health. (2001, March). National standards for culturally and linguistically appropriate services in health care. Retrieved from http://minorityhealth.hhs.gov/assets/pdf/checked/f…

ASSESSMENT INSTRUCTIONS

PREPARATION

Your team has presented its preliminary findings to the executive leadership in your organization, but leadership has some doubts about some of the information they received. Each member of the team has been charged with doing a critical examination of recent research around each member’s area of expertise. As the team’s nursing representative, you need to look specifically at the health care concerns identified in the Windshield Survey assessment.

The first step in preparing to write a review of the research is to define your topic. For this assessment, your review will provide a comprehensive overview of the needs of the population you identified in the Windshield Survey assessment in terms of health promotion and disease prevention, the factors that contribute to health disparities for the population, and the need for the organization to improve health care delivery to the population.

In the Capella library, search for current scholarly or peer-reviewed professional research articles that:

  • Examine the health care risks and needs of your population.
  • Analyze the need to improve health care delivery to the population.
  • Evaluate, critically, the factors that affect health promotion and disease prevention for the population.
  • Examine strategies to reduce health disparities for your population.

Locate at least 5–7 resources so that you can eliminate 2–3 if necessary. You may discover, for example, as you read each article more in-depth, that they may not all have the focus you need for your review.

REQUIREMENTS

For this assessment, you need to develop several points around which to apply the research from the articles you located. Specifically, you need to:

  • Compare statistics for the primary health concern of your population to the rest of the general population in the United States. This would include frequency of occurrence, age groups most at risk, frequency of fatality, and so on.
  • Describe the epidemiological concepts, data analysis methods, tools, and databases used in the research studies you located. Address any flaws or biases you believe are present.
  • Explain the factors that affect health promotion and disease prevention for the population. (Hint: These may be things such as language barriers, cultural values, generational differences, social fear, and access to services.)
  • Describe the types of health care initiatives that have been tried by other organizations specifically for the primary health care concern or the population.
  • Recommend one health care initiative for your population, based on your research,

Marketing and the Health Care System

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Assignment 1: Marketing and the Health Care System

Due Week 4 and worth 300 points

Select a health care provided with which you are familiar and write a four to six (4-6) page paper in which you:

  1. Determine the direct impact of marketing for the health care provider you selected.
  2. Outline a strategy for the health care provider you selected to determine the utilization of its products or services.
  3. Outline a marketing strategy for the health care provider you selected.
  4. Recommend at least three (3) separate ways the health care provider you selected could shape the buying decisions of its customers.
  5. Provide at least three (3) qualified sources, e.g., peer-reviewed journals, professional organization Website, or health care provider Websites.

Your assignment must follow these formatting requirements:

  • Be typed, double spaced, using Times New Roman font (size 12), with one-inch margins on all sides; citations and references must follow APA or school-specific format. Check with your professor for any additional instructions.
  • Include a cover page containing the title of the assignment, the student’s name, the professor’s name, the course title, and the date. The cover page and the reference page are not included in the required assignment page length.

The specific course learning outcomes associated with this assignment are:

  • Describe the health care system and the role of marketing.
  • Analyze the competitive environment of a health services organization and identify a course of action that will allow for strategic marketing success.
  • Use technology and information resources to research issues in health services marketing.
  • Write clearly and concisely about health services marketing using proper writing mechanics.

Grading for this assignment will be based on answer quality, logic/organization of the paper, and language and writing skills.

Click here to view the grading rubric.

Managing Risks for Nurses in Hospitals

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Mini Essay Questions about Managing Risks for Nurses in Hospitals

Reply to each question with a paragraph of 300+ words. All references should be in APA format.

  • Review your hospital’s organization’s risk management policies as they relate to the Americans With Disabilities Act (ADA) and workers’ compensation. Describe the (a) process for reporting an incident. If there is no existing policy, explain the steps in developing and obtaining for a policy within either your organization or a typical health care organization. Support your analysis with a minimum of one peer-reviewed reference.
  • Review your organization’s risk management policies (or those for a typical health care organization) as they relate to the Americans With Disabilities Act (ADA) and workers’ compensation. Describe the (a) process for reporting an incident. If there is no existing policy, explain the steps in developing and obtaining for a policy within either your organization or a typical health care organization. Support your analysis with a minimum of one peer-reviewed reference.
  • The Patient Self-Determination Act (PSDA) was implemented to allow patients to state “Do Not Resuscitate” (DNS), or to assign a surrogate decision maker in the event the individual is unable to make the decision. What relationship does an ethics committee have in enforcing the advance directives of the patients in their care? Support your analysis with a minimum of one peer-reviewed article.
  • The Center for Medicare and Medicaid Services (CMS) publishes a list of health care-acquired conditions (HACs). What actions has your health care organization (or health care organizations in general) implemented to manage or prevent these “never events” from happening within their health care facilities? Support your response with a minimum two peer-reviewed articles.
  • The Joint Commission National Patient Safety Goals (NPSGs) address patient safety issues within health care organizations. First, review the current NSPGs at http://www.jointcommission.org/standards_information/npsgs.aspx. Next, determine three patient safety issues that are being addressed by your health care organization (or health care organizations in general). Lastly, identify the actions the organization is taking, or identify three action-item issues to be addressed by health care organizations in general. What actions should the health care organization take regarding each of these NPSGs, and why? What goals do they need to achieve? Support your responses with a minimum of two peer-reviewed references. (slides attached)
  • The Occupational Safety and Health Administration (OSHA), the Centers for Medicaid and Medicare Services (CMS), and The Joint Commission (TJC) require that health care organizations maintain risk management programs to address infection control. Detail three measures that your health care organization (or any health care organization) needs to address in the delivery of safe health care services. (Example: Placing hand washing devices at all of the public entrances of the health care facility). Support your response with a minimum of two peer-reviewed references.
  • Health care organizations continually face challenges from various regulatory and government agencies, and are also bound by Managed Care Organization (MCO) standards. View the video “College of Nursing and Health Care Professions: Do we know what our future is?” for insight into the challenges of health care reform. http://lc.gcumedia.com/zwebassets/courseMaterialPages/nur508_healthcare-reform-video-series-v1.1.php. Based on the video, describe, with rationale, two key factors that you feel will need to be addressed by future health care workers and health care leaders. (Note: you can download slides from this video within the media piece itself for ease of review in developing your response). Additionally, what role does adherence to MCO standards play in your future health care vision?
  • The Patient Protection and Affordable Care Act (PPACA) of 2010 (section titled “Subtitle D”) identifies requirements relating to provider compliance with fraud, waste, and abuse laws. Identify three measures that your health care organization ((or health care organizations in general) has initiated, or could initiate, to comply with these measures. Support your analysis with a minimum of two peer-reviewed articles.