Performance Assessment Task 530-185

Learning Plan 7 Coding Compliance and Fraud and Abuse

Fraud Trend Analysis

Strategy: Data visualization/critical thinking

Evaluators: Instructor, self

Target Competency: Comply with regulations related to fraud and abuse

Linked External Standards:

III.D.2 Analyze data to identify trends.

V.A.1 Analyze policies and procedures to ensure organizational compliance with regulations and standards.

V.C.1 Identify potential abuse or fraudulent trends through data anlysis.

Blooms Taxonomy Level 4 Analyze

Contribute to the examination of information in part or aggregate to identify motives and causes

Linked Program Outcomes

3.3. Ensure compliance with coding regulations

7.4. Detect fraud and abuse in the revenue cycle

Linked Core Abilities

Communicate Effectively

Think Critically

Introduction:

It is essential to understand the coding compliance issues that influence reimbursement as well as understand the legislation that has been put into place to prevent fraudulent activity in healthcare.

Objective: Identify fraud and abuse risk areas and prevention strategies

Directions:

1. Create one graph to illustrate the comparison of three hospital with the state and national percentages for the distribution of MS-DRGs 190-102 using the data below.
2. When evaluating the trends is it possible that any fraud and/or abuse is occurring? Explain how you would know?
3. Visual display includes comparison of the three hospitals and state and national data as well as percentages for the three hospitals and state and national percentages
4. Analysis of fraud/abuse trends are explained.

MS-DRG 190 Discharges MS-DRG 191 Discharges MS-DRG 192 Discharges

Hospital X 38 Hospital X 23 Hospital X 18

Hospital Y 112 Hospital Y 103 Hospital Y 67

Hospital Z 89 Hospital Z 31 Hospital Z 17

State 8300 State 7912 State 2214

Nation 315400 Nation 290565 Nation 93214