Blowing the Whistle on Healthcare Fraud: Should I?

Diego Guzman

Professor Al Williams
MAN 2010
February 21, 2010

Blowing the Whistle on Health Care Fraud : Should I ?
A whistle blower is defined as an individual who raises a concern about wrongdoing occurring in an organization or body of people, usually this person would be from that organization. This article brings to light the ordeal that individuals, specifically nurses, in the healthcare industry face when contemplating the possibility of whistleblowing. Unfortunately in healthcare, fraud is very easy to cover especially when considering that there are thousands of claims processed on a daily basis. Due to the high number of claims, violators also assume that they are not making a dent in the insurance companies since they have plenty of money as it is. Are these assumptions correct? The National Healthcare Anti-fraud Association estimates a loss of $56.7 to $170billion annually. The numbers are shocking and perhaps yet more eye opening when recognizing that as taxpayers we are also loosing an enormous amount of money due to these fraudulent claims. A doctor may for whatever reason feel compelled to “up code” a service that was provided or even bill for a service that was not performed. As the person of highest authority within the organization, the risks of loosing your job or causing more wrong than good are reasons that would refrain a nurse from whistleblowing. Depending on the severity of the case, possibilities of threats against self and family, and psychological and emotional stress may be inevitable. Although for many the consequences may be sufficient to consider taking the unethical approach of staying quiet, in the end those that are not loyal deal with significant amounts of guilt and ultimately feel they suffer most than those that have dealt with the consequences of whistleblowing. In the end, the nurse’s duty is to familiarize themselves with regulations regarding billing and then if they witness unethical acts, proceed to weigh the pros and cons when considering whistleblowing. From our text we learned that, “Ethics requires courage and it is up to the person to decide what is right and wrong.” In our text we are given the example of the situation between Coca Cola and Pepsi Company. An executive secretary from Coca Cola’s company headquarters contacted Pepsi to offer confidential samples for a price. Instead of accepting her offer, Pepsi decided to contact Coca Cola about the situation, which then resulted in the secretary being fired as well as the FBI becoming involved. Pepsi took the ethical approach when handling the situation and therefore was