If the billing manager reports an increase in correspondence challenging the medical necessity of claims, what should the compliance officer do next?

The best course of action in this scenario is to start an investigation. When there is an increase in correspondence challenging the medical necessity of claims, it signals a potential pattern or issue that needs to be examined closely. Investigating allows the compliance officer to gather more information about the nature of the challenges, identify any underlying causes, and assess whether specific claims practices or documentation are inadequate or out of compliance with established guidelines.

Undertaking an investigation is essential to understanding the full scope of the situation. It helps determine if there are systemic issues that need addressing, whether the challenges arise from provider practices, or if changes in regulation or payer policies affect claims acceptance. Once the investigation is conducted and its findings are understood, the compliance officer can take targeted actions, such as revising billing procedures or conducting staff training, based on factual insights gathered during the investigation period. This evidence-based approach ensures that the compliance officer's response is appropriate and effective in addressing the concerns raised.