As new advanced practice registered nurses (APRNs), it is essential that we are aware that fraud and abuse are major issues in healthcare. According to the Tennessee Department of Finance & Administration (2016, para. 1), fraud is defined as “an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person.” Abuse is defined as when a provider practices “inconsistent with sound fiscal, business, or medical practices, and result in an unnecessary cost to the Medicaid program, or in reimbursement of services that are not medically necessary or that fail to meet professionally recognized standards for health care” (Tennessee Department …show more content…
It is vital that we are billing only for service and time we spend with the patient. Over-coding is when providers bill for services at a higher level of complexity than the service that was provided. It is a serious issue and state and federal governments are focusing resources on investigating and prosecuting those who are over charging for patient care (Joel, 2013). Some institutions hire a staff member to review the patient charts and their job is to specifically code and bill for services hindered to the patient. However, this does not alleviate the APRN from their responsibility. The APRN is the provider that signed the patient’s chart and they will be held accountable. It is essential that as providers we attend in-services, conferences, and stay up to date with billing regulations so that we better understand the details of coding. This will help ensure you are charging for care correctly. According to Kalb (1999, pg. 1163), a provider that bills for false claims is “subject to several criminal, civil, and administrative prohibitions, notably the federal civil False Claims Act”. If issues arise with a provider, the investigating team will look for a pattern of repeated fraudulent activity, not just one case. As healthcare continues to evolve, fraudulent activity is being evaluated closely and serious consequences will result. By making providers more accountable for how they are billing, we can