BHS 499 (Senior Capstone Project) Module 3 CBT - Essay Example

Fraud as defined by the Merriam-Webster Dictionary of Law is "any act, expression, omission, or concealment calculated to deceive another to his or her disadvantage; specifically: a misrepresentation or concealment with reference to some fact material to a transaction that is made with knowledge of its falsity or in reckless disregard of its truth." The HIPAA or Health Insurance Portability and Accountability Act of 1996 defines it as ''a criminal conspiracy or a violation" to specific provisions indicated in the U.S. Code which pertains to conspiracy relating to a health care benefit program'' 18 U.S.C. x 24(a). Furthermore, fraud is basically considered as an act of misrepresentation or deception designed to acquire something of value held by some other; and the most common forms of fraud among nurses documented by CNO include: falsifying a record; collecting pay under false pretenses; misappropriating property or money through deceptive means; and providing false information to ones employer (Quality Practice, 2003; p 1).

Below outlines the managerial, legal, ethical and financial implications brought about by fraudulent and financial abuse in the health care industry. The unnecessary patient treatments that are being ordered, limits the patient's coverage which may be subsequently met prematurely; later, patients may not be able to expend co-payments for gratuitous visits. In addition, false diagnoses for the purpose of up-coding may affect the patient's ability to obtain maintain insurance coverage since the information is available primarily to other potential insurers (Busch, 2007).

According the National Health Care Anti-Fraud Association, around $56.7 to $170 billion is the estimated loss annually (Department of Health and Human Services, 2005). Centers for Medicaid & Medicare (2006) expressed that the dollars lost to reimbursement of Medicare and Medicaid as well as intentional improper billing could have been used to fund the health insurance of low-income persons; if they were not acquired or end up in the pockets of the unscrupulous health care suppliers and providers.

The Provision 3.5 under the Code of Ethics calls upon that all nurses needs to take appropriate action about any instances of unethical, incompetent, illegal or impaired practice by members of the health care team or any action on the side of others by the health care system which places the best interest of the patient (American Nurses Association, 2001). Fletcher, Sorrell, and Silva (1998) have point out that nurses are frequently called upon to make sacrifices, in their personal as well as professional, ones they adhere strictly to Nurses' Code of Ethics.

This code 3requires nurses' accountability as professionals however fails to acknowledge that the reality is that in the health care system, many nurses have limited power within. Job security for fraud investigators and auditors remains strong. Over the years, it continues to attract the nurses who are ethically challenged. Health care fraud is oftentimes buried within the functions in critical business. In 2006, initiatives were made to implement the development of health information technology infrastructure, in order to improve the