Phantom Visit Hunt
Members who say ‘I never went there’ become the fund's fraud detectives.
The job
Turns members' reports of services they never received into provider-fraud cases, with evidence the reports are independent. Estimates the money lost and checks the billing stopped, without ever tipping off the provider.
The moment
Within five weeks, 11 members of the fund with no visible link between them each say they never visited the same clinic. Their reports are pinned up like a detective's corkboard.
A meter checks the reports are independent: 11 different members, 7 districts and 3 channels, so confidence is high. The estimated leak is $1.4 million to $2.2 million.
The head of investigations sends 40 messages asking members to confirm their visits, and 26 reply that they never went. The case is filed with one approved click.
A month later, the audit confirms the clinic was billing for visits that never happened.
What it does
- Open a case from a string
- Pin statements to a case
- Send members a ‘did you visit?’ confirmation
- File the case to the fraud case system
- Record the audit outcome
- Show a card's evidence
What you see
Detective corkboard (pins, index cards, red string with an independence meter) and a case-file drawer
What it moves
Dollars recovered or saved from confirmed billing for visits that never happened, days from the first report to a filed case, and reports about a provider after its audit.
Built for
- Risk & fraud
- Partners & ecosystem
- Compliance, complaints & legal
- Finance
