FAQContact usTerms of servicePrivacy Policy

I have firsthand knowledge of a nurse involved in insurance fraud. Do I have a legal obligation to report this?

Friday January 11, 2013
Printer Icon
Select Text Size: Zoom In Zoom Out
Share this Nurse.com Article
rss feed

Dear Donna,

I feel trapped. I have firsthand knowledge of a nurse involved in insurance fraud. She pays the patient’s mother to sign her paperwork to show she worked on days she did not work. This has happened more than 40 times. The extended family members have notified the agency after the child almost died when the nurse was absent. The agency looked the other way and gave the nurse a verbal warning. She never stopped the fraud. Could she lose her license if reported? Can my license be affected? Do I have a legal obligation to report this?

In a Quandry

Dear Donna replies:

Dear In a Quandry,

If you have first hand knowledge of this, then you have a legal, moral and ethical responsibility to report it. Although I am not an attorney, it is my understanding that if you don't report a crime and it eventually is found out you knew, you can be charged. You also may be in violation of your state nurse practice act for not reporting it.

You don't mention whether you are also an employee of the same agency. If you are, then you should report it to the agency whether or not you believe they already know about it (if you haven't already). Keep detailed records of what you report to whom and the response.

You also should report it to the insurance board in your state and to the state board of nursing. Many (if not all) states have an insurance abuse hotline you can call and even remain anonymous, although it may be better to provide your contact information to support the investigation. Your name likely would be kept confidential. Once the fraud is reported, it will be investigated. There is no way to know for sure what the results of that investigation would be and what actions would be taken. What matters is that the practice be stopped.

Because this has been going on for some time with your knowledge, and to be sure you take the correct steps and protect yourself in the process, I recommend consulting a nurse attorney (versus a non-nurse attorney) for advice on how to proceed.

Best wishes,

Donna Cardillo, RN, MA, well-known career guru, is Nurse.com’s “Dear Donna” and author of “Your First Year as a Nurse: Making the Transition from Total Novice to Successful Professional” and “The ULTIMATE Career Guide for Nurses: Practical Advice for Thriving at Every Stage of Your Career.” Information about the books is available at www.Nurse.com/CE/7010 and www.Nurse.com/CE/7250, respectively. To ask Donna your question, go to www.Nurse.com/Asktheexperts/Deardonna. Find a “Dear Donna” seminar near you: Call 800-866-0919 or visit http://Events.nursingspectrum.com/Seminar.