Unintended Consequences: How wRVU-Heavy Compensation Models Can Put Hospitals and Patients at Risk

Physician compensation models built around productivity have become the norm across healthcare. However, as work RVU–based structures become increasingly complex—and financial pressures intensify—healthcare leaders are confronting a critical question: Are our incentive models unintentionally increasing clinical, financial, and regulatory risk?

That question was at the center of Coker’s recent webinar, Unintended Consequences: How wRVU-Heavy Compensation Models Can Put Hospitals and Patients at Risk. Moderated by Jon Moses, Senior Vice President at Coker, the discussion featured insights from Dan DeBehnke, MD, Senior Vice President and Chief Physician Executive, and Justin Chamblee, President of Coker. Together, they examined how compensation design, physician behavior, and clinical oversight intersect, and where organizations may be vulnerable if these elements are not aligned.

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Why wRVU-Heavy Models Deserve a Closer Look

Work RVUs have long been viewed as the “best of imperfect” productivity measures—closely aligned with fee-for-service reimbursement and relatively easy to administer. As physician employment has increased, wRVUs have become central to most compensation arrangements.

But as Justin Chamblee noted, organizations are feeling growing tension between rising physician compensation rates and declining reimbursement. The result is a steadily increasing investment per physician—putting pressure on margins and, in some cases, unintentionally encouraging higher utilization.

“When rate pressure increases,” Chamblee explained, “the risk isn’t just financial. It’s whether productivity expectations begin to influence behavior in ways the organization didn’t intend.”

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Compliance Risk Is More Than a Dollar Problem

Compensation compliance is often framed around fair market value and commercial reasonableness—and rightly so. But the panel emphasized that compliance doesn’t stop at the paycheck.

FMV and CR analyses may validate the economics of an arrangement, but they don’t always explain how productivity is achieved. Without additional guardrails, organizations may overlook utilization patterns that raise red flags long before compensation crosses a numerical threshold.

“Compliance isn’t just about what you pay,” Chamblee said. “It’s also about how that compensation is earned.”

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The Physician Perspective: Incentives Shape Behavior—Not Intent

Dan DeBehnke cautioned against assuming bad intent when utilization patterns change. Most physicians are not trying to “game” compensation models; they are responding rationally to the systems and expectations placed in front of them.

“Physicians generally come to work thinking about their patients—not how to maximize RVUs,” DeBehnke said. “But behavior follows incentives, even when intentions are good.”

The risk, he explained, is systemic rather than individual. Without thoughtful design and oversight, even well-meaning physicians may drift toward patterns that create compliance exposure or clinical variation.

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Where Clinical Risk Enters the Picture

Jon Moses shifted the conversation closer to the patient, where compensation incentives and clinical decision-making can collide.

Drawing on decades of experience in clinical compliance and peer review, Moses highlighted common areas where concerns about overutilization arise, including cardiac interventions, spine procedures, joint replacements, wound care, and other discretionary services.

“These are not theoretical risks,” Moses said. “We see real cases where unnecessary procedures lead to patient harm—and in some instances, loss of life.”

He emphasized that false claims exposure does not require malicious intent. Documentation gaps, coding creep, patient pressure, defensive medicine, and competition for block time can all influence clinical decisions in ways that place organizations at risk.

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The Rising Stakes: Corporate and Board-Level Exposure

Regulatory scrutiny continues to intensify, with DOJ and OIG enforcement actions on the rise. Beyond government penalties, Moses warned of a growing trend toward corporate negligence claims, where organizations are accused not only of creating risky incentives but of failing to monitor their effects.

“Plaintiffs are increasingly arguing that hospitals knew—or should have known—about patterns of unnecessary care and failed to act,” Moses noted.

For compliance and finance leaders, this elevates the importance of proactive oversight, cross-functional collaboration, and documented intervention processes.

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Building Guardrails That Actually Work

Throughout the discussion, the panel returned to a central theme: prevention is possible—but it requires alignment across compensation, clinical oversight, and governance.

Key strategies discussed included:

• Soft compensation caps that trigger review rather than arbitrarily limiting earnings
• Strong governance structures, including engaged compensation committees
• Integrated data monitoring, combining financial, utilization, and quality signals
• Clinical peer review and audit programs that focus on education—not punishment
• Breaking down silos between compliance, finance, quality, and medical staff leadership

“Compliance works best when it’s done with physicians, not to them,” Moses said. “Transparency and education matter.”

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Aligning Incentives With Patient-Centered Care

Ultimately, the panel agreed that compensation models are not inherently flawed—but they must be designed and monitored with intention.

“When incentives, oversight, and culture are aligned,” DeBehnke concluded, “organizations can reward productivity while protecting patients, providers, and themselves.”

For healthcare leaders navigating these challenges, the message was clear: compensation strategy cannot live in isolation. It must be paired with clinical insight, proactive monitoring, and a shared commitment to doing the right thing—before unintended consequences arise.

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Want to continue the conversation?

Coker’s Clinical Advisory team collaborates with compliance and finance leaders to assess physician compensation models, identify utilization risks, and enhance governance and clinical oversight—enabling organizations to stay compliant while delivering high-quality patient care.