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    Discussion: Reimbursement Issues for Nurse Practitioners
    Understanding the complex process of accurate coding and billing is essential to a sustainable practice. As NPs, we are ultimately responsible for ensuring all coding and billing is accurate for each patient seen. For this Discussion, you will search the health care literature and summarize a peer-reviewed journal article published within the last five years.

    To prepare:
    Select one of the following topics:
    Applying for Medicare and Medicaid Provider Numbers
    Application process for National Provider Identifier Number
    Incident to billing
    Coding-Evaluation & Management
    Fraudulent billing
    Billing Self-Pay patients
    Managed Care Organizations
    Conduct a search and select a peer-reviewed journal article published within the last five years related to the topic you selected.
    Note: For this Discussion, all students are to avoid all written work, which reviews or outlines coding and billing at previous or current worksites as well as previous or current practicum sites.

    By Day 3
    Post a brief summary of the article you selected. Include the key reimbursement issue addressed and how they would impact the NP in a collaborative practice versus and independent practice. Discuss an ethical or legal implication(s) associated with your article.


Subject Nursing Pages 4 Style APA


Fraudulent Billing

Fraudulent billing is a form of Medicare/healthcare fraud which involves healthcare providers billing for services that they did not provide. Additionally, fraudulent billing can be upcoding whereby providers bill for a higher level of service provided (Manary et al., 2015). Unbundling, which is billing each step of a procedure as if it were a separate one, constitutes fraudulent billing. Many research articles have been published on the aspect of fraudulent billing. This paper provides a discussion of the article titled Medicare fraud in the United States: can it ever be stopped? authored by Hill et al. (2014) and published in the health care manager journal.

Article Summary

The aim of the article by Hill et al. (2014) was to explore the current status of Medicare fraud in the United States and further identify existing laws and policies which foster Medicare fraud. After conducting a literature review on the aspect, the authors established that some of the examples of Medicare fraud include billing for services not furnished, billing for unnecessary services, upcoding, and misrepresenting diagnosis to justify payment (Hill et al., 2014). Additionally, there has been an increase in fraudulent claims in the US over the years which has resulted in the implementation of additional laws and policies to combat frauds in billing (Hill et al., 2014). However, the conclusion made by the authors is that Medicare fraud is persistent and the existing laws and policies have not been enough to control them.

Key Reimbursement Issue Addressed

                The key reimbursement issue which has been addressed in the article by Hill et al. (2014) is that of billing and in specific, fraudulent billing. Although the focus was on the broad topic of Medicare fraud, fraudulent billing has been extensively discussed in the article. Hill et al. (2014) define fraudulent billing as claiming of reimbursements for bills which have been made from various fraudulent activities such as upcoding, billing for services not provided, billing for services which are ordinarily not insurance billable, and billing for services which were provided but not necessary. According to Hill et al. (2014), fraudulent billing has resulted in a huge financial loss for the government. Additionally, there has been a rise in the number of individuals who have been charged with criminal fraud arising from fraudulent billing.

Impact on NP in a Collaborative Practice versus and Independent Practice

Nurse practitioners can either work together (in collaboration) or independently in assessing, diagnosing, and caring for their clients. Fraudulent billing will have various impacts on the nurse practitioners working in collaborative practice versus those working in independent practice. For those working in collaborative practice, fraudulent billing will result in a lack of trust among the various healthcare practitioners as they will be oblivious of the fact that the services they offer can be fraudulently billed (Poghosyan, Boyd, & Knutson, 2014). For independent practice, the effect of fraudulent billing is that the nurse practitioner practicing independently will be held responsible alone for the fraudulent bills. Additionally, the focus on the money, as opposed to the quality of services provided, might result in poor patient outcomes in independent practice. However, in both forms of practice, fraudulent billing leads to legal cases associated with those being charged with criminal fraud.

Ethical or Legal Implication(s) Associated with the Article

The issue of medical fraud which has been discussed in the Hill et al. (2014) presents various ethical issues. One of the issues is honesty. In specific, providers/billers are entrusted with the medical information, the collection of money, and expected to follow various billing guidelines. However, providing fraudulent bills to insurance service providers is a violation of the ethical issue of honesty (Manary et al., 2015). The ethical aspect of confidentiality arises from the article by Hill et al. (2014) as in fraudulent billing, providers of care manipulate the confidential information of their patients without their consent. Professional integrity is another aspect arising from the article as practitioners are expected to display a high level of integrity. However, fraudulent billing is an affront to the ethical issue of professional integrity.

In conclusion, fraudulent billing can be demonstrated by various actions such as upcoding, billing for services never provided, and even for unnecessary services. In the article chosen from research, the main reimbursement issue presented is that of Medicare fraud. In specific, the article argues that cases of fraud in billing have been on the increase in the US and have resulted in huge financial losses to Medicare. Fraudulent billing result in loss of trust among nurse practitioners working in collaborative practice. For those in independent practice, fraudulent billing can make them be charged with criminal fraud. However, in both sets of practice, fraudulent billing will affect the quality of services provided to the clients. The article has various ethical implications as fraudulent billing is an affront to the values of honesty, confidentiality, and professional integrity.




Hill, C., Hunter, A., Johnson, L., & Coustasse, A. (2014). Medicare fraud in the United States: can it ever be stopped? The health care manager33(3), 254-260.

Manary, M., Staelin, R., Boulding, W., & Glickman, S. W. (2015). Payer mix & financial health drive hospital quality: Implications for value-based reimbursement policies. Behavioral Science & Policy1(1), 77-84.

Poghosyan, L., Boyd, D., & Knutson, A. R. (2014). Nurse practitioner role, independent practice, and teamwork in primary care. The Journal for Nurse Practitioners10(7), 472-479.















Appendix A:

Communication Plan for an Inpatient Unit to Evaluate the Impact of Transformational Leadership Style Compared to Other Leader Styles such as Bureaucratic and Laissez-Faire Leadership in Nurse Engagement, Retention, and Team Member Satisfaction Over the Course of One Year

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