Week 6 Organizational Ethics Presentation
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week6organizationalethicspresentation.pptxOccupational Fraud and Abuse, Including Conflict of Interest and Healthcare Fraud Kandi Zielinski West Coast University Nursing: 521 Organizational Ethics Dr. Jackson 10/18/2020
Introduction-Healthcare Fraud
Fraud as truth’s misrepresentation or fact’s concealment to mislead a person
Intended act of depriving another of money through deception
Intended cheating or fact’s falsification
Fraud examples:
billing unprovided services or offered goods for payment
misrepresentation of previously offered services
forging healthcare records
falsifying cost statements
kickbacks for referrals
Fraud involves well-calculated actions or practices done intentionally to misrepresent, cheat, falsify, deceive, and mislead a person to gain a specific payment of benefit. The intentional misleading or misinterpretation by an individual already knowing that cheating could lead to unapproved advantage to himself or another individual (Abu et al., 2020). All types of fraud are actionable under Federal or State law such as False Claim Act or Criminal Healthcare Fraud Statute.
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Continued-Healthcare Abuse
Healthcare abuse as inconsistent with:
business practices
sound fiscal practices
medical practices
reimbursement for services
Example of healthcare abuse:
misuse of codes on claim
hiked costs for services or supplied goods
extra and unsupported billing
Abuse implies practices that are incorrect, unsuitable, and beyond the boundaries or standards of medical or nursing professional code of conduct. These actions fail to satisfy the professional standards that are recognized as healthcare. The abuse also involves recipient practices that are leading to unwanted cost to Medicaid on health insurance programs.
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Conflict of interest
Prioritizing personal instead of needs of other people
No gifts accepted in the hospital
Healthcare providers embrace on leave or maintain a patient’s comfortability
Tips influence minds of care workers
Conflicts arise from interfering with a person’s interests. Healthcare facilities may have implemented policies that ensure patients’ experience is positive. Without these policies, tipping is prohibited since it leads to conflicts (Mackey, 2020). As a result, practices such as tipping may turn to be a way of committing fraud or abusing the office.
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Documented Facts on Healthcare Fraud
More money spent in healthcare, in 2018 $3.6 trillion was spent
Tens of billions each year are lost due to fraud
Healthcare fraud is a crime
Healthcare fraud leads to a patient injury under federal law
The United States in 2018 used $3.6 trillion on healthcare. According to the National Health Care Anti-Fraud Association, the approximated loss incurred each year due to healthcare fraud and abuse is in terms of tens of billions of dollars (Blythe and Goodpasture, 2019). Currently, healthcare fraud is a crime following the 1996 Health Insurance Portability and Accountability Act. Also, the federal law sets a term of 20 years for healthcare providers found guilty of fraudulent activities.
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Registered Nurse Fraud and Falsified Medical Records
Manipulating computer records for self interest
Not reporting the truth about patient’s vital signs and symptoms
Assuming the health condition of a patient
Nurses have been prosecuted and imprisoned for engaging in committing fraudulent activities in their profession. For instance, falsifying computer health records may lead to wrong medication prescription, thereby leading to death. Despite a patient being in a stable and manageable condition, RNs may prescribe for them medicines for a person in a critical condition to meet their interests from committing the act (Blythe and Goodpasture, 2019). In this situation, an RNs ignore and assume care of veterans, a situation that leads to further problems.
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continued
Failure to enter the right vital signs into record of patient
Changing electronically stored record to make it look as if patient is in good term or condition
Intentionally not informing care providers of patient’s worsening condition
RN fraud and professional abuse may involve intentional actions intended to worsen the condition of a patient. When a physician fails to enter a patient’s critical signs into an electronic record for some time, the intention may be to manipulate or short-change the treatment process for self-gain (Howard and Desai, 2020). Also, an RN may not inform his colleague about a patient’s vital signs, thereby leading to wrong treatments that can even cause death.
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Code of Ethics in Nursing Profession
A nurse is an advocate responsible for safeguarding rights and health safety of a patient
All unethical actions or behaviors are unacceptable among nurses
A nurse needs to expose areas where medication mistakes or errors appear to happen
Nurses are responsible for unethical conduct or action
Healthcare providers need to take responsibility when discharging their duties. They need to be alert to take the best and ethical action when providing care services. Illegal, unethical, and impaired action or practice are not at the interests of a patient. Instead, nurses should account for their actions to ensure they comply with ethics while at the place of work. Uncorrected unethical practice or action leads to more chances of committing fraud , an action that is not ethical.
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Ethical Principles
Beneficence
Non-maleficence
Veracity
The above two ensure a nurses does not engage in fraud or abuse
Nurses should follow and work under the framework of ethical principles of justice, kindness, nonmaleficences, accountability, fidelity, autonomy, and veracity. Kindness includes or involves doing good and the right thing for the patient or at the interest of the patient. On the other hand, nonmaleficence makes sure that a nurse does not cause harm; he or she acts ethically (McDermott-Levy et al., 2018). Harm may be intentional or unintentional. Veracity ensures a nurse becomes honesty and truthful with patients. A care provider should not withhold the whole truth from clients even when it may result in patient embarrassment.
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Continued
Autonomy
Justice is fairness
Fidelity
Justice requires a nurse to do what is fair to a patient, especially when distributing care. Care services should be fair and equitable when being distributed. Fidelity is honoring promises without any form of fraud or abuse of the profession. An RN needs to be faithful and true to nursing professional values, roles, and duties by giving high quality, safe care in a competent approach. Also, upholding autonomy implies giving a patient his right to make decisions, give views, opinions, perspectives, values and beliefs about his treatment(McDermott-Levy et al., 2018).
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Lessening the Impact
The maintenance of accuracy in medical records
Complying with available nurse practice Acts of a state
Completing and sending incident report immediately
All nurses should take responsibility for ensuring the patient’s entered data into an electronic record is accurate. Errors in the information imply negligence and get connected to acts or avenues of committing fraud (Mackey, 2020). Also, when inaccuracies persist, it means an intention to twist evidence to undermine justice being served to patients. Also, reporting cases of fraud and abuse to relevant authority can help in preventing the occurrence of unethical acts.
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Continued
Designing compliance program
Implementing ongoing education for nurses
Conducting disciplinary actions
Jailing nurses involved in occupational fraud and abuse
The development of a compliance program is crucial to prevent healthcare fraud and abuse of the profession. A significant program consists of a hospital culture that enhances recognition of good conduct and avoidance of unethical practices (Ingham-Broomfield, 2017). Also, the enforcement of nurses’ education programs may help in educating them on how to avoid temptations leading to committing fraud and abusing their positions. Any disciplinary action taken against involved nurses will help in teaching others the consequences such as the imprisonment of participating in unethical practices such as frauds.
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Continued
Understanding health care laws
Ensuring accurate billing
Maintaining updated records
Avoiding unnecessary referrals
Taking all RNs under law class or session may assist them better understand the False Claims Act that prevents nurses from submitting false claims. Under this law, a person gets fined $11, 000 for every false claim made (Howard and Desai, 2020). Also, placing great trust in nurses may imply accurate billing. Through the Anti-Kickback Statute and Stark Law, nurses investing in other practices have higher risks of engaging in fraudulent deals. So, it becomes crucial to avoid such refers to safeguard integrity at work.
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References
Abu Amuna, Y. M., & Abu Mouamer, F. (2020). Impact of Applying Fraud Detection and Prevention Instruments in Reducing Occupational Fraud: Case study: Ministry of Health (MOH) in Gaza Strip. International Journal of Advanced Studies of Scientific Research, 4(6).
Blythe, S., & Goodpasture, J. E. (2019). Nursing home fraud schemes: Forensic accounting lessons from litigation. International Journal of Healthcare Management, 1-8.
Howard, D. H., & Desai, N. R. (2020). US False Claims Act Investigations of Unnecessary Percutaneous Coronary Interventions. JAMA Internal Medicine, 21(3), 53.
Ingham-Broomfield, R. (2017). A nurses' guide to ethical considerations and the process for ethical approval of nursing research. Australian Journal of Advanced Nursing, The, 35(1), 40.
Mackey, T. K., Miyachi, K., Fung, D., Qian, S., & Short, J. (2020). Combating Health Care Fraud and Abuse: Conceptualization and Prototyping Study of a Blockchain Antifraud Framework. Journal of Medical Internet Research, 22(9), e18623.
McDermott-Levy, R., Leffers, J., & Mayaka, J. (2018). Ethical principles and guidelines of global health nursing practice. Nursing Outlook, 66(5), 473-481.
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