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Archives for August 2019

August 19, 2019 By SmartLight News Desk

Phantom billing: Can you spot it in your claims?

Three seemingly unrelated imaging providers based in FL were identified in a self-funded employer’s medical claims for what was later verified as phantom billing.


The utilization patterns seen in paid claims history for an employee and his wife indicated a strong probability of “phantom” billing – billing for services never performed. Phantom billing typically involves setting up fake corporation(s) with the intent of billing non-rendered services. The individuals involved with the phantom corporations will then recruit patients by offering them an incentive in exchange for allowing their insurance to be billed.

Patients will also be offered incentives to recruit other members of the same insurance plan. Phantom providers start and stop billing within a short period of time in order to avoid detection.

Filed Under: costs, healthcare Tagged With: claims, phantom billing

August 19, 2019 By Asha George

Cosmetic Surgery Is Ripe for Fraud

Multiple healthcare fraud schemes have been investigated over the years involving providers who misrepresent cosmetic procedures as medically necessary ones to increase patients and their profit. Rhinoplasty is known to be the most common procedure that is inappropriately billed to health insurance. Surgeons charge for repair of a “deviated septum” and then perform cosmetic rhinoplasty. Tummy tucks have also been billed to insurance as hernia repair. Separation of the abdominal muscles is sometimes falsely called a hernia and billed to insurance.


Any effective wasteful spend analysis should routinely conduct review of a focused sample of medical records as an identification and prevention measure. We posted last week about one case.


An example can be seen from a selected visits review ($10,000 – $30,000/per procedure): A 26-year-old female was billed for reduction mammoplasty by a Beverly Hills plastic surgeon. Services that are typically seen prior to this procedure, i.e. physical therapy for back pain or related office visits, were not seen in this member’s medical history prior to surgery.

Filed Under: costs, healthcare Tagged With: claims, cosmetic surgery, fraud

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