Fraudulent Billing and Legal Implications Essay

Fraudulent Billing and Legal Implications Essay

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Fraudulent Billing and Legal Implications Essay

In the article by Brenner, Teo, and Bal (2017), it is explained that the United States has the highest healthcare expenditures of other nations, such as the United Kingdom, Australia, Germany, and France, and that the federal government is concerned that fraudulent billing may be responsible. Fraudulent billing is when a healthcare provider attempts to obtain monetary gain from any healthcare benefit program through false billing or other misrepresentations (Brenner, Teo, & Bal, 2017).

A statute titled 18 U.S.C. § 1347 states that in order for the government to obtain conviction, the guilty party is not required to have knowledge of the relevant law or specific intent to commit violation of that law (Brenner, Teo, & Bal, 2017). Many healthcare providers will receive penalties and fines for fraudulent billing, but criminal penalties, such as prison, are also a possibility (Brenner, Teo, & Bal, 2017).

Collaborative Versus Independent Practice

A nurse practitioner is always responsible for the care that she gives to her patient, regardless of practicing independently or collaboratively. The well-written medical record is imperative because it may be the only defense for the nurse practitioner in a claim of fraud or malpractice.

Being found guilty of billing fraud may result in being unable to bill insurance and maintain licensure (Dolan & Farmer, 2016). The medical record can demonstrate that fraud did not occur, the standard of care was met, safety principles were followed, and the best practice was rendered (Dolan & Farmer, 2016).

The primary difference in fraudulent billing between collaborative and independent practice is that when services are billed under the collaborating physicians NPI number, that physician may incur repercussions, as well (Rapsilber, 2019).

These repercussions include jail time, fines, and relinquishing of ability to bill insurances (Rapsilber, 2019). Executives in positions of authorities can, also, be held accountable due to failure in its oversight duty to monitor (Brenner, Teo, & Bal, 2017).

References

Brenner, L. H., Teo, W. Z. W., & Bal, B. S. (2017). Medicolegal sidebar: expanding hospital liability-the concept of willful blindness. Clinical Orthopaedics & Related Research, 475(5), 1315. https://search-ebscohost-com.ezp.waldenulibrary.org/login.aspx?direct=true&db=edb&AN=122406803&site=eds-live&scope=site.

Dolan, C. M., & Farmer, L. J. (2016). “Let the record speak. . .”: The power of the medical record. The Journal for Nurse Practitioners, 12(2), 88–94. https://doi-org.ezp.waldenulibrary.org/10.1016/j.nurpra.2015.09.018

Rapsilber, L. (2019). Coding & billing practices. Incident to billing in a value-based reimbursement world. Nurse Practitioner, 44(2), 15–17. https://doi-org.ezp.waldenulibrary.org/10.1097/01.NPR.0000552680.76769.e5.

Fraudulent Billing and Legal Implications Essay

RUBRIC
Excellent Quality 95-100%	Introduction 45-41 points The background and significance of the problem and a clear statement of the research purpose is provided. The search history is mentioned.		Literature Support 91-84  points The background and significance of the problem and a clear statement of the research purpose is provided. The search history is mentioned.			Methodology 58-53 points Content is well-organized with headings for each slide and bulleted lists to group related material as needed. Use of font, color, graphics, effects, etc. to enhance readability and presentation content is excellent. Length requirements of 10 slides/pages or less is met.
Average Score 50-85%	40-38 points More depth/detail for the background and significance is needed, or the research detail is not clear. No search history information is provided.		83-76  points Review of relevant theoretical literature is evident, but there is little integration of studies into concepts related to problem. Review is partially focused and organized. Supporting and opposing research are included. Summary of information presented is included. Conclusion may not contain a biblical integration.			52-49  points Content is somewhat organized, but no structure is apparent. The use of font, color, graphics, effects, etc. is occasionally detracting to the presentation content. Length requirements may not be met.
Poor Quality 0-45%	37-1 points The background and/or significance are missing. No search history information is provided.		75-1 points Review of relevant theoretical literature is evident, but there is no integration of studies into concepts related to problem. Review is partially focused and organized. Supporting and opposing research are not included in the summary of information presented. Conclusion does not contain a biblical integration.			48-1 points There is no clear or logical organizational structure. No logical sequence is apparent. The use of font, color, graphics, effects etc. is often detracting to the presentation content. Length requirements may not be met
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