Whistleblowing in Nursing - Brown, LLC

Whistleblowing in Nursing

September 22, 2023

Nurses as Heroes in Uncovering Healthcare Fraud

Nurses play a vital role within the healthcare system, not just with protecting their patients as they often have more contact time with them than physicians, but in protecting the integrity of the system and routing out fraud. Since they have a direct pulse of what is charted and what health care services are performed, they are in a superior position to uncover and address instances of healthcare fraud. Further, if a nurse is curious about what is legal and what is not and also wants to know what their options are in filing an action under the False Claims Act to see if they’re eligible for whistleblower rewards then they should have consultation with a whistleblower law firm. Some of the best whistleblower law firms offer free confidential consultations, as well as provide off and weekend hours when it may be most convenient for the nurse to speak.

Nurses as Detectives for Healthcare Fraud

Nurses possess a distinctive role as both insiders and observers within the realm of healthcare. This insightful position provides them with the ability to perceive nuances that might evade others – such as manipulative tactics employed by hospitals, pharmaceutical companies, and nursing homes and they may be able to blow the whistle and stop unlawful practices as well as what’s been seen as a trend over the last decade, insiders who have blown the whistle on health care fraud have in aggregate received over a billion dollars in whistleblower awards. The False Claims Act addresses fraud against the government such as Medicare fraud, Medicaid fraud or Tricare fraud and certain states like California and Illinois have statutes that address systemic private insurance fraud. Nurses have consistently acted as heroes in having unlawful practices come to light like:

Off-label marketing by drug representatives: Pharmaceutical fraud can occur in many ways, some of which is off label promotion by drug companies through its sales representatives. Nurses can be instrumental in flagging instances where pharmaceutical companies engage in off-label drug marketing, which endangers patient safety to chase profits.

Billing irregularities: Nurses’ watchful eyes have exposed improper use of tests and procedures, leading to inflated healthcare billing – a direct threat to the integrity of the healthcare system. A skilled nurse will have a sense when something is ordered reflexively even though it shouldn’t be or if something is performed routinely that is not needed.

Upcoding of services: Nurses’ vigilance has unveiled deliberate exaggeration to receive a higher level of reimbursement than entitled to. Oftentimes, this is an inflated amount of time spent per patient for a higher code, or an exaggeration about the severity of the encounter for a higher code, both resulting in a higher level of billing. Oftentimes, the health care practitioner will give explicit instructions to bill an encounter a certain way regardless of the actual amount of time spent which will give rise to an upcoding claim. Similarly, the nurse may know of unbundling of billing, that is separating the dates of services to bill more separately, then the actual billing for the consolidated encounter.

False claims: Nurses have been champions in revealing cases where healthcare providers bill for services never rendered, sometimes referred to as phantom encounters. Anything put in for reimbursement that is not truthful could be considered a false claim The extent of fraud that occurs is only limited by the imagination of the fraudster and the government may not know a new scheme, however a nurse may

have a pulse for what’s improper, or at least enough of a suspicion to know to call a whistleblower lawyer.

Billing for absent doctors’ services: Nurses’ sharp observations have spotlighted instances where healthcare facilities charge for procedures performed by absent doctors. This sometimes occurs when one physician is properly credentialed and others lack credentials or worse are on an exclusion list.

Nurses are deeply committed to both patient well-being and the responsible allocation of financial resources within the healthcare sector. Their genuine concern drives them to actively combat instances of healthcare fraud By thwarting fraud in healthcare, nurses contribute significantly to upholding the integrity of the healthcare system, which ultimately benefits both patients and the broader community.

Legal Protections and Incentives for Medicare Fraud Whistleblowers

There’s a protection in place for those who step up against healthcare fraud against the federal government’s programs like Medicare, Medicaid and Tricare, and it comes in the form of the False Claims Acts. For other healthcare fraud protections for disclosing fraud against private insurance it will be on a state by state basis, most states have some modicum of protection, but states like California and Illinois in addition to protection allow the whistleblower to receive up to 50% of what the government recovers as a whistleblower award. The anti-retaliation provisions provide for double damages and attorneys fees and costs in most jurisdictions, but the best whistleblower law firm will help you plan for what could occur and make sure you invoke your whistleblower rights properly.

When nurses come forward to report instances of fraud that result in the recovery of lost funds, they may be eligible for a whistleblower award, under the False Claims Act from 15% to 30% of the recovered funds which incentivizes whistleblowers to step forward.

Nurse Heroes and Challenges

Embracing the role of a nurse comes with its share of challenges. At times, nurses find themselves working alongside individuals who lack honesty, or they may grapple with concerns about potential job repercussions if they choose to speak out. However, these dedicated professionals are steadfast in their commitment to doing what is ethically correct. They recognize the importance of their actions in upholding the integrity of the healthcare system. Importantly, nurses are not on this journey alone; they have a support network that stands behind them.

Nurses aren’t limited to discussing fraud verbally – they need to document it as well. Keeping track of dates, times, names, and all pertinent details proves invaluable in these cases, however one shouldn’t gather evidence without legal guidance, and further one shouldn’t access information that they are normally not entitled to. The American Nurses Association emphasizes the importance of confiding in trusted individuals outside the situation and consulting legal experts for advice before proceeding with any actions.

Heroes for Health

Nurses wield a unique and significant influence in the battle against healthcare fraud, serving as both caregivers and watchdogs of the system. Beyond their compassionate patient care, nurses hold the responsibility of safeguarding the financial aspects of healthcare. Their dual role positions them at the

frontline of detecting and addressing instances of fraud, making them pivotal players in maintaining the system’s honesty.

By actively identifying and reporting fraudulent activities, nurses contribute to a healthier and more equitable healthcare landscape. If you happen to come across such fraudulent activities and want to discuss your rights, you should speak with a whistleblower law firm like Brown, LLC (877) 561-0000 to understand your rights.