Ambulatory Reimbursement


You are the Billing Supervisor for a physician practice. A data entry staff member reports to you that she noticed that one of the physicians always bills for a level 4 or 5 for each of their encounters. The data entry staff member does not have access to the physician’s documentation, just the encounter form. What would you do?

Option 1: Ignore the report, since her observations are based on incomplete data, and this is outside the scope of her job anyway.

Option 2: Report the physician for Medicare fraud since this is highly suspicious and you want to protect the organization from a fraud scheme.

Option 3: Recommend to the compliance office that a statistically valid sample of this physician’s encounters be reviewed to determine if the levels assigned on the encounter forms are supported by the documentation in the encounters.

Prepare an initial post which includes the following:

Which option would you choose and why?

Remember to cite any references that you use to support you