You notice a diagnostic provider submitted a large number of claims for a particular procedure, much higher than other providers. What should you do?

• A. Ignore the anomalies
• B. Inform the provider to reduce charges
• C. Audit the same type of claims from others but take no action
• D. Consult with immediate supervisor for next steps or contact the compliance department (via compliance hotline or SIU)

Answer: (D)

Unusual billing patterns for a single procedure are a red flag for possible fraud, waste, or abuse and should trigger formal escalation rather than casual handling. The right move is to notify the appropriate authority within your organization—your immediate supervisor or the compliance department—using the established channels (such as a compliance hotline or the Special Investigative Unit). This starts an official review, preserves documentation, and ensures the issue is investigated in a controlled, compliant way.

Why this approach fits: it activates risk management processes, directs the matter to people with the authority to assess risk, and helps determine whether corrective actions, referrals, or other steps are needed. It also protects patient privacy and maintains an audit trail.

Why the other options aren’t appropriate: ignoring the anomalies lets potential misuse continue; auditing others without taking action doesn’t address the immediate red flag or trigger necessary investigations; and directly telling a provider to reduce charges bypasses governance controls and could create liability or compliance problems.