BHA FPX 4006 Assessment 2 Health Care Fraud and Abuse

BHA FPX 4006 Assessment 2 Health Care Fraud and Abuse

BHA FPX 4006 Assessment 2 Health Care Fraud and Abuse


Capella university

BHA-FPX4006 Health Care Regulation and Compliance

Prof. Name


Major Categories of Health Care Fraud and Abuse

Fraud and abuse pose significant challenges in the healthcare sector, impacting taxpayers, patients, and various entities involved. The National Healthcare Anti-Fraud Association (n.d.) reported that in 2018, healthcare expenses amounted to 3.6 trillion dollars, with a substantial portion allocated to healthcare insurance claims. Shockingly, health care fraud and abuse are estimated to cost the United States a staggering 68 billion dollars annually (Blue Cross Blue Shield, n.d.). The Federal Bureau of Investigation (FBI) spearheads investigations into fraud and abuse (Health Care Fraud, 2022), while the Office of Investigation General (OIG) oversees governmental oversight, combating fraud, waste, and abuse (Office of Inspector General, n.d.).

It is crucial to distinguish between fraud and abuse, as outlined by the Centers for Medicare and Medicaid Services (2021). Fraud entails intentional deception for personal or financial gain (Office of Inspector General, 2018), often employing sophisticated techniques facilitated by technological advancements (Schwayder, 2021). In contrast, abuse involves the inappropriate or excessive use of resources to deceive or harm, potentially resulting in financial or non-financial violations (Office of the Inspector General, n.d.).

The primary categories of healthcare fraud and abuse encompass phantom billing, billing for nonexistent patients, anti-kickback violations, upcoding service claims, unbundling related services, and provision of medically “unnecessary” services (Moseley, 2013).

BHA FPX 4006 Assessment 2 Health Care Fraud and Abuse

Five Health Care Fraud and Abuse Laws

Federal healthcare programs like Medicaid and Medicare are safeguarded by laws aimed at combating and preventing fraud and abuse (Centers for Medicare and Medicaid Services, 2021). These laws include the False Claims Act (FCA), the Anti-Kickback Statue (AKS), the Physician Self-Referral Law (STARK Law), the Civil Monetary Penalties Law (CMPL), and the Exclusion Statue (Centers for Medicare and Medicaid Services, 2021).

The False Claims Act serves as a robust tool against healthcare fraud, protecting the government from fraudulent claims and imposing hefty penalties on violators (Office of Inspector General, 2011). Similarly, the Anti-Kickback Statue criminalizes inducements for referrals, with penalties including fines, imprisonment, and program exclusion (Office of Inspector General, n.d.).

Physicians are prohibited from self-referral to designated health services under the STARK Law, which mandates fines and program exclusion for violations (Office of Inspector General, n.d.). Moreover, the CMPL authorizes civil monetary penalties for Medicaid and Medicare fraud and abuse, while the Exclusion Statue mandates exclusion from federal healthcare programs for convicted individuals (Office of Inspector General, n.d.).

Upcoding and the Law

Upcoding, a prevalent form of healthcare fraud, involves billing for higher-reimbursing services than those rendered (National Health Care Anti-Fraud Association, n.d.). This deceptive practice violates the False Claims Act and results in overcharging federal programs (Office of Inspector General, n.d.).

Recent lawsuits highlight instances of upcoding, such as the case against Kaiser Permanente, accused of submitting inaccurate code diagnoses to Medicare Advantage for increased reimbursements (Payne, 2021). Similarly, CareWell Urgent Care Center settled FCA claims for overbilling Medicare and Medicaid for unnecessary medical services (PR Newswire, 2019).

Identifying and Addressing Upcoding in Health Care

Preventing upcoding necessitates compliance with federal healthcare laws and regulations, along with accurate coding, billing, and physician documentation (Office of Inspector General, n.d.). Internal monitoring, auditing, and staff training are vital for ensuring compliance and early detection of fraudulent practices (Office of Inspector General, n.d.).

Efforts to combat upcoding and other forms of fraud and abuse are essential to preserving trust in healthcare providers and safeguarding federal healthcare programs (Howard, 2020). Reporting suspected fraud and abuse is imperative, with resources such as hotlines and governmental websites available for whistleblowers (Office of Inspector General, 2019).


All About E/M Codes. (2022, June 11). Retrieved October 17, 2022, from

Blue Cross/Blue Shield. (n.d.). Fraud Statistics.

Centers for Medicare and Medicaid Services. (2021). Medicare fraud & abuse: Prevent, detect, report.

BHA FPX 4006 Assessment 2 Health Care Fraud and Abuse

Department of Justice. (2019). Three physicians and five marketers charged for violation to federal anti-kickback statue. The United States Attorney’s Office, Northern District of Oklahoma.

Health Care Fraud. (2022). Federal Bureau of Investigation. Retrieved October 16, 2022, from

Schwayder, J. (2021). Health care fraud exposed: The penalties of deception can be much worse than medical negligence. Contemporary OB/GYN, 66(7), 30–32.