Contributor: T’Neecia Leigh Applewhite MBA MS APRN FNP-C

Nurses are not just the backbone of the healthcare systems worldwide but also the vigilant guardians against healthcare fraud. As the largest and most trusted healthcare occupation in the United States, with over 3.4 million registered nurses, we are more than just healthcare workers. We are innovative trailblazers with unique skill sets involving listening, problem-solving, and thinking outside the box. We take a little information, transform it, and know how to manage resources to implement the finished product. As we cultivate the spirit of inquiry and emerge as Nursologists dedicated to knowledge and research, we must also embrace our crucial role in recognizing and reporting healthcare fraud, a realm rarely discussed. 

Healthcare fraud and abuse refers to deceptive practices in the health industry that lead to undeserved profit for some and increased costs for consumers (Health Care Fraud and Abuse, n.d.). The most common types of healthcare fraud include Health Insurance and Medical Billing, Medicare and Medicaid Fraud, Home Health Care Fraud, and Drug and Abuse Fraud (Health Care Fraud and Abuse, n.d.).

Reporting healthcare fraud, also known as whistleblowing, is an ethical activity that tries to end wrongdoing; it is an act that alerts internally and externally to stakeholders organizational deviance and misconduct (Bron, 2019; Pohjanoksa et al., 2017). Initially considered an act of disloyalty, blowing the whistle quickly became celebrated when Watergate and the Pentagon Papers were released, exposing government and private sector devilment and alerting the public to undercover high-profile scandals and potential disasters (Bron, 2019). Nurse whistleblowers like myself are highly educated and view reporting ethical concerns as integral to protecting the organization, patients, and themselves (Cleary & Duke, 2017).

From a nursology student’s perspective, using Barbara Carper’s theory, Fundamental Patterns of Knowing, recognizing healthcare fraud requires Aesthetic Knowing, a way of knowing realities that are not empirically observable, and Ethical Knowing, the moral obligation to report it (Carper, 1978). 

Carper’s aesthetic knowing, a key concept, involves perception. It is an awareness and response to an intuitive consciousness in reality. In the context of healthcare fraud, this means that the fraud is often felt first, before it is discovered, due to the intuitive nature of Carper’s aesthetic knowing. When intuition becomes a reality, Carper’s definition of ethics, nursing’s moral knowledge that guides decision-making, should influence the nurse to act. 

Consider a patient who becomes the victim of Medicare fraud committed by a provider who orders a genetic test and is reimbursed by Medicare but has no intention of following through with the results. The patient suffers psychological and possible physical harm if cancer is present and there is a delay in diagnosis and treatment. Additionally, reimbursement costs have to be absorbed. Now multiply this scenario by tens of thousands. This is the reality of healthcare fraud.

Nursing researchers often conduct studies to benefit patients and ameliorate illness and disease. Nursologists can contribute to science and the profession by developing a spirit of inquiry for detecting and identifying fraud, which may deter these perpetrators and keep medical-related costs low to keep healthcare affordable. The answer lies in developing an atypical spirit of inquiry for an uncommon aesthetic and remembering our ethical obligation to our patients and ourselves.

References

Boykin, A., Parker, M. E., & Schoenhofer, S. O. (1994). Aesthetic knowing
grounded in an explicit conception of nursing. Nursing Science Quarterly,
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Bron, I. (2019). Vile wretches and public heroes: A survey of canadian
whistleblowing literature. Canadian Public Administration, 62(2),
356–361. https://doi.org/10.1111/capa.12324

Busch, R. S. (2012). Healthcare fraud: Auditing and detection guide (2nd
ed.). Wiley.

Carper, B. A. (1978). Fundamental patterns of knowing in nursing. Advances in Nursing Science, 1(1), 13–24.
https://doi.org/10.1097/00012272-197810000-00004

Cleary, S., & Duke, M. (2017). Clinical governance breakdown: Australian
cases of wilful blindness and whistleblowing. Nursing Ethics, 26(4),
1039–1049. https://doi.org/10.1177/0969733017731917

Health care fraud and abuse. (n.d.). Texas Attorney General. Retrieved
April 30, 2024, from
https://www.texasattorneygeneral.gov/consumer-protection/health-care/health-care-fraud-and-abuse

Pohjanoksa, J., Stolt, M., Suhonen, R., Löyttyniemi, E., & Leino-Kilpi, H.
(2017). Whistle-blowing process in healthcare: From suspicion to
action. Nursing Ethics, 26(2), 526–540. https://doi.org/10.1177/0969733017705005

U.S. Bureau of Labor Statistics. (2023). Spotlight on statistics.
Retrieved April 30, 2024, from
https://www.bls.gov/spotlight/2023/healthcare-occupations-in-2022/home.htm#:~:text=In%202022%2C%2014.7%20million%20people,of%20every%205%20healthcare%20workers .

About T’Neecia Leigh Applewhite MBA MS APRN FNP-C

Tneecia L. Applewhite is a distinguished Family Nurse Practitioner and Entrepreneur based in Dallas, TX. With a diverse professional background spanning various facets of healthcare and business, Ms. Applewhite has garnered extensive experience. Her journey includes roles in a level-one trauma center, fertility, pre-op, PACU, phase-two recovery units, operating rooms, med-surg, emergency rooms, post-cath recovery, urgent care, telemedicine, and locum tenens assignments across the United States. As an astute entrepreneur, Ms. Applewhite is the proprietor of Clarity Medical Group, a telemedicine company, and Elements Health Care Consultants LLC, serving as an American Heart Association Training Center. Before commencing her Ph.D. in Nursing Science in 2021, she was a full-time faculty member for the Texas Woman’s University College of Nursing FNP program.

Ms. Applewhite holds a degree in Finance from the University of North Texas, an MBA from the University of Phoenix, and Bachelor’s and Master’s degrees in Nursing from Texas Woman’s University. Certified by the American Association of Nurse Practitioners as a Family Nurse Practitioner, she possesses multiple RN and APRN licenses across the US. Her research pursuits as a Nurse Scientist focus on health disparities, child sexual abuse, healthcare fraud, waste and abuse, and the impact of unregulated histamine on idiopathic illness. She anticipates defending her dissertation and earning her Ph.D. in Nursing Science in Fall 2024.

An active member of professional organizations, Ms. Applewhite belongs to Sigma Theta Tau International Honor Society of Nursing, the American Nurses Association, the Texas Nurses Association, and the American Association of Nurse Practitioners. Additionally, she dedicates her time as a Court-Appointed Special Advocate (CASA) volunteer. Ms. Applewhite’s commitment to community and leadership extends to her role as an elected member of the Board of Governors at Tower Club Dallas, where she chairs the Diversity, Equity, and Inclusion Committee.

Ms. Applewhite is a firm, fair, and a strong advocate for the nursing profession.