How it works
Provider collusion is coordinated billing between parties that are meant to be independent. Practices refer patients to each other in closed loops regardless of clinical need, a cooperating prescriber writes scripts that a linked pharmacy dispenses and bills, or providers pay each other for referrals.
Members are often part of the scheme. Recruiters sign members up, sometimes paying them for the use of their membership number, and route them to a provider group that bills each visit at a high level of care. Brokers and administrative staff at the medical scheme, insurer or a hospital can supply member details.
A single provider’s claims can look normal: the codes are valid, the member is covered and the provider is registered. The collusion appears in the links between providers and members, such as shared bank accounts, owners, addresses or phone numbers, referral flows that stay inside a small group, and members who all present at the same set of practices.
Red flags
- Referrals that circulate within a small group of practices with common owners or addresses
- Separate practices paid into the same bank account, or sharing directors, phone numbers or staff
- Members from unrelated employers or regions visiting the same group of providers on the same days
- Members unable to describe the treatment billed, or reporting payment for their membership details
- Claim volume rising sharply after a recruiter becomes active in an area
- Routine visits billed at the highest level of care across the group
Signals the engine evaluates
- Shared bank accounts, addresses, phones and owners resolved across provider records on the network graph
- Concentration of referral flows between providers, against specialty peer baselines
- Member overlap between providers that should have independent patient bases
- Provider billing mix and level-of-care coding against specialty and regional peers
Investigation and response
- 01Place linked providers on payment review and pend new claims for verification
- 02Contact a sample of members to confirm attendance and the treatment billed
- 03Request clinical records and referral letters, and audit them against the billed codes
- 04Refer the network to SIU, recover confirmed overpayments, and report to the professional regulator or law enforcement as required