BHA-FPX4006 Assessment 1: Compliance Program Implementation and Ethical Decision Making

Billing for services not rendered.

Audit and overpayment recoupment refer to billing for services not rendered, which comprise an overpayment that becomes debt providers owe to the federal government. It is an act of fraud punishable by law (Hoover et al., 2020)

Use of unlicensed staff

Unlicensed staff or personnel refers to a person other than a physical therapist or physical therapist assistant who performs patient-related tasks consistent with the unlicensed personnel’s education, training, and expertise under the direct on−premises supervision of the physical therapist (Borson, 2022). Therefore, practicing without a license is the Act of working without the licensure offered for that profession in a particular jurisdiction. It is against the law to practice or use unlicensed personnel to undertake activities that require licensure. Such actions are retrogressive to the law and hence have penalties for practicing without a valid license.

Altering medical records.

Changing medical data implies tampering with the evidence. Such proof will destroy the defendant’s integrity before a jury and leave the strong impression that they are trying to conceal the truth. Evidence showing that a record has been altered can force the settlement of an otherwise defensible case (Elsayed, 2020).

 Drug diversion

Drug diversion is the criminal dissemination or abuse of prescription drugs or their use for purposes not intended by the prescriber. Prescription drug diversion may occur as prescription drugs are distributed from the manufacturer to wholesale distributors, pharmacies, or the patient (Ford & Grape, 2019)

Kickbacks and bribery.

A bribe is an Act or practice of giving or receiving something of value to corruptly influence the actions of another, most commonly to influence a contract award or the execution of a contract (Ford & Grape, 2019). On the other hand, a kickback is a bribe paid incrementally by the contractor as it is paid, usually an agreed percentage of the contract. In the health care setting, for example, when a physician or medical provider uses any payment or compensation to encourage a patient to come to their office or to promote another medical provider to refer patients to their office or facility.

Billing Practice Known as Upcoding

Upcoding is a category of fraud where healthcare providers submit incorrect billing codes to insurance institutions to receive inflated reimbursements. The most substantial impact of Upcoding is the increased cost to health payers—which they extrapolate on to consumers (Milcent, 2021). When government payers end up paying excessive money for health care, this is reflected in taxes and governments’ budgets.

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