Which of the following situations could trigger an audit?

• A. Billing for unnecessary services; Overcharging for services; Billing for services/supplies not provided; Misusing billing codes to increase reimbursements; Paying for referrals
• B. Billing for unnecessary services only
• C. Billing for services actually provided
• D. Submitting claims after the audit is completed

Answer: (A)

Audits are triggered by red flags of improper billing and potential fraud. The scenario that includes billing for unnecessary services, overcharging, billing for services or supplies not provided, misusing billing codes to increase reimbursements, and paying for referrals signals multiple serious violations of billing and procurement rules. These behaviors point to fraudulent or abusive practices that payer review bodies and regulators actively look for, making an audit highly likely to verify accuracy, necessity, and legality of claims and arrangements.

If a situation involves billing only for unnecessary services, it still raises concern, but on its own it may not show the broader pattern that merits an investigation. Billing for services actually provided is compliant and would not prompt an audit for fraud. Submitting claims after an audit is completed could raise questions, but audits focus on patterns across claims and arrangements rather than a single post-review submission; the combination of several improper practices is the strongest indicator that an audit is warranted.