How it works
Many consultation, therapy and anesthesia codes are time-based or have a typical duration. When a provider’s billed services for a day are added up, the implied time can exceed the hours one practitioner could work. Impossible days also include services billed at two facilities at the same time, or for a member who was admitted to hospital elsewhere.
The excess usually comes from phantom services added to a genuine list, short visits coded as long ones, or billing under one practitioner’s number for work done by unregistered staff or several colleagues. Practices that share billing staff or an outsourced billing agent can show the same pattern across several providers.
Each claim is valid in isolation, with a real member, a registered provider and an allowed code. The impossibility appears only when claims are aggregated per provider per day and the implied hours are compared with the working day, the provider’s own history and peers in the same specialty.
Red flags
- Total billed time per day that exceeds a realistic working day, often on consecutive days
- Services billed at two locations at overlapping times
- Outpatient visits billed on days the member was an inpatient elsewhere
- High volume on weekends and public holidays that does not fit the practice’s hours
- Long-duration codes billed for nearly every visit
Signals the engine evaluates
- Implied billed hours per provider per day, based on code durations, against the working day and specialty peers
- Overlapping service times for the same provider across locations, or for the same member across providers
- Share of long-duration and high-level codes against the provider’s own baseline
- Conflicts between outpatient claims and inpatient admissions for the same member
Investigation and response
- 01Pend claims for the affected days and request appointment books and clinical notes
- 02Verify attendance with a sample of members billed on those days
- 03Establish whether other practitioners or unregistered staff delivered services billed under the provider’s number
- 04Refer to SIU, recover confirmed overpayments, and report to the professional regulator where required