Reimbursement Issues for Nurse Practitioners

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Fraudulent billing

Nursing practice has several issues of consideration in ensuring that there is efficiency in service delivery. It is important to understand the complex process of accurate coding and billing in the health care sector. As nurse practitioners, there is an ultimate responsibility of ensuring that all coding and billing is accurate and for every patient seen (Buppert, 2015). The essay provides a summary if an article that focuses on a reimbursement issue and how it impacts the nurse practitioner in a collaborative practice and independent practice. Also discussed is the ethical and legal implication associated with the article. The issue selected for discussion is fraudulent billing.

Fraudulent billing is a major problem in the United States in which the National Health Care Anti-Fraud Association estimates the financial losses to health care fraud averaging tens of billions of dollars annually. In 2011, the government spent $2.27 trillion on health care and more than four billion health insurance claims. Some of the insurance claims are fraudulent. Each procedure performed by a doctor or a health care provider has a billing code used by the providers to submit claims to the insurance companies.

The article selected regards corporate responsibility and pharmaceutical fraud. According to Valverde (2012), the health care fraudulent practices cost billions of dollars every year. The author identifies that fraud and corruption occur in any health care system. It is important to address health care fraud for the well-being of citizens and the entire economy. Fraud in the healthcare sector is hard to detect, and a major concern has been the pharmaceutical manufacturers and distributors. The pharmaceutical industry faces intense criticism due to the reality of its conduct despite the self-serving proclamations of high ethical standards. The number of schemes to defraud the health insurance is high in which the target companies are Medicare, Medicaid, and other health insurance providers. Some providers collaborate with the companies through kickbacks to induce a referral or reward for the past referrals and false reporting.

Fraudulent billing through the collaboration with the pharmaceutical industry has a negative impact to the nurse practitioner in a collaborative practice versus independent practice. According to Valverde (2012), the False Claims Act helps to recover payments made to entities or individual providers in pretense. The Act imposes civil liability on the provider that submits a fraudulent claim for payment to the U.S Government. Making a false record or statement to get a fraudulent claim paid by the government has a legal liability.

It is unethical for the manufacturer’s attempts to encourage through bribing the health care providers to prescribe a particular drug through a fraudulent billing cartel. The doctors and other care providers get or provide kickbacks for business or referrals through fraudulent billing agreements with the provider companies. Most of the pharmaceutical fraud activities result in false claims to the insurers or programs of the health care system for financial gain both to the provider and the company (Valverde, 2012). For the independent practice, the nature of the fraudulent billing is no different from collaborative practice. Whistleblowers initiate the cases of billing fraud or detected through unusual billing patterns.

The majority of Fraudulent billing in health care sector is perpetuated by some dishonest health care providers. The types of billing frauds engaged in can be in the form of services, misrepresentation of the non-covered treatments, accepting kickbacks for referrals, and over-billing the insurance carrier. The practices are unethical and tend to interfere with the reputation of the care providers. It also subjects them to legal liabilities upon engagement.



Buppert, C. (2015). Reimbursement for nurse practitioner services: In Nurse practitioner’s             business practice and legal guide (5th ed.). (303-319). Burlington, MA: Jones & Bartlett.

Valverde, J. L. (2012). Corporate responsibility and pharmaceutical fraud: Pharmaceuticals          Policy & Law, 14(2-4), 129-156.

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