When a provider's claim submissions appear unusually high relative to peers, what is the proper course of action?

• A. Increase payments to resolve the discrepancy
• B. Ignore the discrepancy
• C. Notify the patient
• D. Consult with immediate supervisor for next steps or contact the compliance department (via compliance hotline or SIU)

Answer: (D)

Noticing a provider’s claim submissions that are unusually high compared with peers signals a potential fraud, waste, or abuse issue that needs formal review. The proper course is to escalate through the right channels—talk with the provider’s immediate supervisor and/or contact the compliance department via the established reporting mechanism, such as a compliance hotline or the Special Investigations Unit (SIU). This approach brings in trained investigators to assess the pattern, preserve evidence, and determine if an audit or deeper analysis is warranted, all while protecting confidentiality and maintaining program integrity. Taking independent or last-minute actions, like increasing payments, ignoring the discrepancy, or warning the patient, would either enable potential misuse or fail to address the risk appropriately.