Fraud and abuse of the system are common issues in health care delivery. Individuals who engage in fraud and abuse are often seeking to gain access to the millions of dollars that are available for provision of medical care, whether that be through government schemes such as Medicare and Medicaid or through the abuse of private insurance companies (Lee and Oral, 2014). The main area of health care associated with fraud and abuse is the administration sector, which handles billing, coding, and reimbursement (Walton, 2015). The definition of fraud as given by HIPAA is the knowing execution (or attempt) to defraud a health care benefit program or obtaining money or property associated with that program. Individuals can engage in this fraud by false pretenses or representations of themselves to gain access to that funding (Walton, 2015). Abuses are generally associated with an initial unintended practice that degenerates into fraudulent invoices submitted to billing departments (Lee and Oral, 2014). Fraud and abuse cost the health care industry millions of dollars every year and, whilst not completely preventable, can be targeted by health care providers in such a way to prevent large-scale damage to the company (Mayer, 2015).

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Fraudulent billing is a common example of fraud, and whilst mainly associated with the administration procedure, can also have an impact on the clinical side of practice. Organizations that are continually victim to fraudulent billing, perhaps by not having enough safeguards in place, are evidently likely to struggle in terms of funding. This has an impact on staffing levels, for example, as the organization may not be able to hire enough staff to meet the needs of the patients (Mayer, 2015). The organization may also not be able to cover necessary improvements in technology or equipment due to the loss of billed funds (Walton, 2015). Administrative departments also have to spend considerable amounts of time assessing and reporting incidences of fraudulent billing, which can also spill over into practice by making it difficult to bill and code the expenses for patients who are not engaged in fraudulent behavior. Patients who are engaged in fraud or abuse may also do so in such a way that wastes the time of clinical staff, meaning that they do not have enough time to meet the needs of existing patients (Walton, 2015). A claim based on a falsified illness, for example, will have this type of impact on clinical practice.

The professional nurse can serve as a client advocate to impact current fraud and abuse in the health care system. Several professional nursing organizations, for example, have information about how to identify and target fraud from a nursing perspective (Walton, 2015). Additionally, the nurse can lobby hospital administration to develop better safeguards and protocols to prevent and deal with fraudulent activity in the system. Nursing leaders are also responsible for ensuring that their organizations are in compliance with federal health care laws, which cover the remit of fraud and abuse and provide guidance on how to report fraudulent behavior in health care (Walton, 2015). Finally, the professional nurse can ensure that they are able to detect risks and translate this risk into programs and policies that are designed to target and prevent fraud (Walton, 2015). These actions are likely to improve the overall state of fraud in the health care industry, especially if professional nurse leaders act together to ensure that patients and staff members are protected from fraud and abuse of the system. Although fraud is likely to be an issue for some time, there are actions that can be taken to help minimize damage.

  • Lee, N. R., & Oral, O. P. (2014). The Changing Face of Healthcare Fraud and Abuse in America. American Journal of Nursing, 114(2), 10–15.
  • Mayer, S. (2015). Those Scamming Little Rascals: Power Wheelchair Fraud and the Flaw in the Medicare System. DePaul J. Health Care L., 17(1), 149.
  • Walton, A. (2015). Counteracting Fraud, Waste and Abuse in Drug Test Billing. American Journal of Nursing, 112(1), 1101–1121.