REIMBURSEMENT ISSUES FOR NURSE PRACTITIONER 5
ReimbursementIssues for Nurse Practitioner
ReimbursementIssues for Nurse Practitioner
of the article
Thearticle in question is titled, AFraudulent Scheme`s Particularity Under Rule 9 (b) of the FederalRules of Civil Procedure.The author discusses the relationship and implications of the FalseClaims Act to reimbursement in nursing practice. According to theauthor, Mitchell Charis Ann, the federal government has madesignificant strides in recovering money received by clients under afalse claim. Mitchell, however, notes that a lot has to be done inorder to prevent people from cheating the government to pay falseclaims. The False Claims Act gives individuals the power to file alawsuit against an individual cheating the government to reimburse afalse claim under federal programs such as Medicaid and Medicare, butthe improper interpretation and application of the Federal Rule ofCivil Procedure 9(b), which imposes the burden of particularity forany individual bringing a lawsuit against another party suspected tobe fraudulent(Mitchell,2015). Rule 9(b), as observed by Mitchell insists that the accusermust demonstrate that a relator must meet the impossible threshold ofparticularity. Many courts have attempted to be lenient when facedwith false claims cases, but relaxing pleading standards have nothelped relax the unrealistic particularity standard due to one singlereason: courts often pay undue attention on specific pleading in thewrong context of an action prescribed by the False Claims Act withthree conditions. Some of the reasons the author includes:
The claim must be related to a federal fund
The claim must be false and
The defendant must have satisfactory knowledge of the falsity.
Theauthor observes that Rule 9 (a) presents a serious discrepancy thatmakes it impossible for a relator in a claim to bring a successfullawsuit against. The House of Representatives is considering anamendment to fix the rules and procedures of the law in order to makethe particularity condition more flexible for any relator. Theamendment is will be a great step forward in enabling the governmentto recover money lost through false claims.
Themain reimbursement issue addressed
Themain reimbursement issue being addressed in the current legalframework that a practicing nurses face in terms of lodginglitigation against suspected fraudulent clients. A nurse is in abetter position to detect and report a false claim. If the legalenvironment gives a nurse a huge burden of proof against a client,nurses are likely to be discouraged or deterred from participating ina transparent billing program for the benefit of the public.
Theimpact of fraudulent billing on nursing practice
Fraudulentbilling has the potential to affect the professional reputation of apracticing nurse whether they work in a collaborative or independentsetup. In the event that a claim is submitted in court, the nurse whoinitiated the billing is likely to be embroiled in litigation. Thedirect implication is for practicing nurses to be familiar with thebilling rules and procedures so that they improve their ability todetect fraud and report(Giles,2015). They can also participate in lobbying so that legal thresholdsof the False Claims Act do not create a technical impediment fornurses to file suits.
LegalImplications of fraudulent billing
Thelegal implications of fraudulent billing are a possible change of lawto reduce the burden of proof. The probable legal changes that arelikely to occur may target the entire billing process and thelitigation process under the False Claims Act (Law,2014). Improvements of the legal framework should target aspects suchas continuous training and education of practicing nurses, federalfraud detection and enforcement anti-fraud procedures,computer-assisted coding, and data mining and modeling.
Giles,C. (2015). Neither Strict Nor Nuanced: The Balanced Standard forFalse Claims Act Pleading in the Eleventh Circuit. University ofMiami Law Review, Forthcoming.
Law,F. K. (2014). Proper Pleading or Premature Proof: Rule 9 (B)`sParticularity Requirement and the False Claims Act. Ga. L. Rev., 49,855
Mitchell,C. A. (2015). A Fraudulent Scheme`s Particularity Under Rule 9 (b) ofthe Federal Rules of Civil Procedure. Liberty University Law Review,4(2), 4.