Illegal Billing Practices

Reimbursement procedures are complex and detailed, especially those associated with government programs such as Medicare. Part of the regulatory requirements of Medicare is to prevent illegal billing practices such as churning, upcoding, and unbundling.Review the latest enforcement actions on this website. Identify a case where at least one of the following illegal actions was used—churning, upcoding, and unbundling.

  • What are some of the specific examples of actions taken against providers engaged in these practices?

To support your work, refer to the readings and relevant outside research.

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There are several different types of studies that can help make data from research credible and therefore useful to healthcare managers and leaders. Credible data is vital to making safe decisions. From thorough research of at least three credible sources, please discuss the following tools used in research:

  • Case-control studies
  • Cohort studies, retrospective and prospective
  • Randomized clinical trials

Include the following key concepts in your discussion of each study:

  • Data that can be collected and used by healthcare leaders and managers
  • Inherent biases
  • Cost effectiveness
  • Level of reliability using the hierarchy of evidence rating method
  • An example of the study

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