How it works
Phantom billing charges for care that never happened. A provider submits claims for consultations, procedures, tests, medicines or equipment using real member numbers, sometimes with the member’s knowledge and often without it. The services may be entirely invented or added to a genuine visit.
Member details come from past patients, recruiters or staff at a practice, hospital or administrator. Billing is spread across many members at modest values so that no single member account draws attention. Claims may continue after a member has died or moved to another plan, or cover chronic medication and appliances the member never received.
Each claim uses valid codes and an active member, and the amounts sit within tariff. What stands out is the provider’s overall profile, such as volume per member, services per day, or a billing mix that departs sharply from peers in the same specialty and region.
Red flags
- Members who do not recognize the provider or the service when shown their claims statement
- Claims dated after the member’s death or after cover ended
- Billing for chronic medication or devices with no matching prescription or delivery record
- Steady, evenly spread claims across many members with few corrections or rejections
- Claim volume rising with no matching growth in practice capacity or staff
Signals the engine evaluates
- Provider claim volume, value and services per member against specialty and regional peers
- Shift in a provider’s billing mix or volume against its own historical baseline
- Claims dated after a member’s date of death or the end of cover
- Shared bank accounts, addresses and phones linking the billing provider to other flagged providers
Investigation and response
- 01Pend payments to the provider while a sample of claims is verified
- 02Contact members directly to confirm the visit, service or delivery
- 03Request appointment books, clinical notes, stock records and delivery confirmations, and reconcile them to the claims
- 04Refer to SIU, recover confirmed overpayments, and report to the professional regulator or law enforcement