What is fraud? According to Penner (2014) fraud occurs when intentional deception is used to obtain something of worth. In healthcare this deception is committed to obtain monies for services not rendered or up coding of patient diagnosis and/or services (Grant-Kels, Kim, & Graff, 2016). The National Health Care Anti-Fraud Association (NHCAA) 2018 is led to believe the majority of health care fraud is committed by a minute number of unethical providers. These unethical providers have belittled the profession and tarnished the trust between provider and patient.

Nursing plays a key factor in ensuring fraud is caught when suspicions arise. According to Penner (2014) the nurse should diligently chart to ensure cares provided are accurately depicted. Remember those days in which our instructors and preceptors continually told us “if it wasn’t charted it wasn’t done”. Well here is a perfect example of why charting is such an important part of patient care. Penner (2014) goes on to add the importance of nurses understanding how and what should be billed.  Lastly, ensuring two patient identifiers are used for verification of patient to avoid identity fraud, as well as, healthcare fraud.

According to the NHCAA healthcare fraud comes with a hefty penalty. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) established health care fraud as a federal crime. Large fines, and up to ten years in a federal prison are just some of the rewards one will gain for committing fraud.

 

References

Grant-Kels, J. M., Kim, A., & Graff, J. (2016). Billing and up coding: What is a doctor-patient to  do? International Journal of Women’s                   Dermatology, 2(4): 149–150.  doi: 10.1016/j.ijwd.2016.08.003

National Health Care Anti-Fraud Association. (2018). The challenge of health-care fraud. Retrieved from                                                                           https://www.nhcaa.org/resources/health-care-anti-fraud-resources/the- challenge-of-health-care-fraud.aspx

Penner, S. J. (2014). Economics and financial management for nurses and nurse leader, (2nd ed.). New York, NY: Springer