The pressure to optimize revenue and manage provider compensation can sometimes blur the line between operational efficiency and ethical responsibility. When financial incentives begin to influence clinical decision-making, medical group leaders must pause and ask: Are we still putting patient care first?
In this episode of the Ask MGMA Podcast, senior advisor Cristy Good explores how billing practices intersect with ethics, compliance and equitable access to care.
Her conversation with host Daniel Williams sheds light on common pitfalls and offers practical strategies to help medical practices uphold integrity while navigating the complexities of RVUs, patient scheduling, and compensation models.
Providers Cannot Choose Patients Based on Billing
When a nurse practitioner requests to only see OB patients whose visits would generate individual wRVUs, red flags are immediately raised.
“It’s not appropriate or ethical for a provider to selectively see patients based on reimbursement or RVU generation,” Good says. She emphasizes that such conduct—often labeled as “billing gamesmanship”—violates professional standards and undermines equity in healthcare.
This behavior is not just an ethical misstep; it may also breach compliance standards and lead to legal ramifications. Providers have an obligation to deliver care based on clinical need, not on the reimbursement potential of a billing code. As Good highlights, “Providers are ethically obligated to deliver care based on medical need, not financial return.”
Ethical Concerns and Legal Risks
The ethical implications of billing-based patient selection extend beyond provider behavior. “First, it compromises equitable access to care… it leads to inequality,” Good notes.
When providers opt out of treating patients with bundled billing codes or certain payer types, it can disproportionately affect Medicaid recipients, the uninsured and underserved populations. Moreover, inaccurate or manipulative billing practices may trigger scrutiny from the Centers for Medicare & Medicaid Services (CMS) and commercial payers.
“CMS and commercial payers actively monitor for unusual billing patterns,” Good warns. Such deviations can lead to penalties, audits, or worse—reputational damage for the organization.
Understanding When Patient Selection is Justified
While providers must avoid financial motivations in patient selection, there are operationally sound reasons to limit patient panels—if done transparently and equitably.
Good offers examples, such as specialists who perform time-intensive procedures requiring special scheduling (e.g., colonoscopies or EMGs) or practices that limit new patients to preserve panel capacity.
Crucially, such policies must apply uniformly across all payer types. Consistency and fairness must be at the core of patient acceptance policies.
“Any policy that limits patient access must be uniformly applied across payer mix and based on operational needs, not reimbursement value,” Good says.
Aligning Ethics with CMS and Professional Guidelines
Good reminds listeners that ethical billing principles are supported by guidance from the American Medical Association (AMA), CMS, and other professional organizations. “Organizations like AMA stress that coding should reflect services rendered, not reimbursement goals,” she notes.
Failure to follow these guidelines may be perceived as intent to manipulate the system—opening the door to serious compliance risks. CMS has little tolerance for perceived “gaming” of billing models. Good warns, “If they even think you’re doing anything that is a selective treatment pattern, CMS will come looking.”
Best Practices for Ethical Billing
Good outlines three best practices for group leaders to navigate these issues:
- Develop Written Policies: These should define provider panels, patient acceptance criteria, and RVU allocation in clear, operational terms.
- Conduct Regular Audits: Leaders should proactively identify and correct any biases in visit type patterns or RVU attribution.
- Adopt Blended Compensation Models: These models balance wRVU productivity with other performance indicators such as patient access, care quality, and team-based contributions.
These approaches discourage cherry-picking of high-reimbursement visits and help foster a more equitable clinical environment.
The Real Problem Isn’t RVUs
A critical distinction Good makes is that wRVUs themselves aren’t the issue—it’s how they are used. “RVUs are a useful metric, but they shouldn’t drive clinical decision-making.”
Over-reliance on RVUs as a measure of value can distort a provider’s role, compromising patient access and quality outcomes. Instead, RVUs should be part of a balanced scorecard that includes other ethical and performance considerations.
As Good emphasizes, “The goal is to balance RVUs with patient access, quality outcomes, and team-based performance.”
Ethical Billing Is High-Integrity Care
Good concludes with a clear message: Ethical billing isn’t just about checking a compliance box—it’s about maintaining the integrity of care.
"Keep your policies transparent, visit them often, and train your team to understand what is allowed and why it matters,” she advised.
For leaders unsure about a specific situation, Good encouraged seeking guidance. “It’s always worth taking that moment and saying, ‘What am I doing, and should I be doing this?’”
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