When a hotline caller reports coding discrepancies, what should the compliance professional do first?

In cases where a hotline caller reports coding discrepancies, the first action a compliance professional should take is to design a review to find facts related to the complaint. This is essential for several reasons.

First, identifying the facts surrounding the reported discrepancies is critical to understanding the scope and nature of the issue. Conducting a review allows the compliance officer to gather pertinent information, assess whether there has been a violation of compliance standards, and understand the context of the discrepancies. This step is foundational in determining the appropriate next steps and ensuring that any corrective actions are based on accurate and thorough information.

Moreover, a thorough review helps in documenting the process of addressing the complaint, which is vital for compliance purposes and for potential audits or investigations. It demonstrates the organization's commitment to addressing issues raised by hotline callers and reinforces a culture of compliance and accountability.

Simply directing the coding supervisor to follow existing policies or incorporating the issue into a future risk assessment does not address the immediate need to understand the problem at hand. Engaging outside counsel might be necessary later in complex cases involving legal implications, but the first priority should be to establish a clear understanding of the discrepancies reported. Thus, initiating a fact-finding review is the most logical and responsible first step in the compliance process.