a. Information gathering: Describe how you would gather information about the incidence of upcoding that occurred at the hospital.

b. Analysis: Identify two key account balances likely to be affected by the upcoding fraud and identify the key assertions most at risk for those account balances.

c. Evaluation: Evaluate how the upcoding fraud impacts the nature, timing, and extent of substantive procedures for the key account balances impacted by the fraud.

d. Analysis: Formulate a plan for how ADA could be used as a substantive procedure for the key account balances impacted by the fraud.

Goodfellow & Perkins LLP is a successful mid-tier accounting firm with a large range of clients across Texas. During 2022, Goodfellow & Perkins gained a new client, Brookwood Pines Hospital, a private, not for-profit hospital. The fiscal year-end for Brookwood Pines is June 30. You are performing the audit field work for the June 30, 2023, fiscal year-end.

When doctors and other medical personnel provide services to patients, they record the procedures performed in the patient’s medical chart using a code. The codes are standardized across the healthcare industry and consist of three main code sets: ICD, CPT, and HCPCS. Using a coding system is more efficient and data friendly compared to writing a narrative about the procedures performed.

The doctors and nurses that staff the emergency room department are all employees of BPH. They are not contracted to use hospital facilities like specialty doctors. In September 2022, a nurse from the emergency room unit reported to the accounting department that she suspected two doctors were “upcoding.” Upcoding is a fraud that occurs when medical providers use codes for more complex procedures than those that were actually performed. The result is the patient and/or patient’s insurance are charged for the more complex and more expensive procedures. The hospital performed an internal investigation and discovered that the doctors were upcoding. The two doctors were fired in early October 2022.