Services
Document a loss
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For carriers and employers
Service areas
Middle Tennessee
- Nashville
- Clarksville
- Murfreesboro
- Franklin
- Hendersonville
- Smyrna
- Spring Hill
- Gallatin
- Lebanon
- Columbia
- Brentwood
- Mount Juliet
- La Vergne
- Cookeville
East Tennessee
West Tennessee
Medical Billing Fraud: Field Checks on Billed Visits
Delator Claims Division helps workers' compensation carriers, self-insured employers, third-party administrators, SIUs and their counsel test billing questions in the field. Investigators check whether billed visits are consistent with activity that can be observed or publicly verified. Delator does not audit codes.
- Coverage
- 95 of 95 counties
- Dispatch
- 24 / 7 / 365
- Metro response
- Under 60 min avg.
- Statewide
- 4-hour guarantee
What this service covers
A bill asserts that something happened: a patient was seen, on a date, at a place, for a stated length of time. Some of those assertions can be checked from the outside. Was the office open that day? Was the claimant observed somewhere else at the billed hour? Does the volume of billed sessions fit a suite with one treatment room and a short posted schedule? A field investigator can gather those facts for the client's reviewers.
The service is for payers and those acting for them. It is not offered to claimants or providers. Delator does not review medical records, does not assess whether a billing code was correct, and does not access protected health information without proper authorization. It offers no view on medical necessity. The investigator supplies observed facts tied to dates, and the client's bill reviewers, SIU and counsel decide what the comparison shows.
Billing questions that fieldwork can test
- Therapy sessions are billed for dates when surveillance already in the file shows the claimant at home or out of town.
- A provider bills for visits on a holiday, a Sunday or a date when the building appears to have been closed.
- Billed session counts per day seem high for a small office, and the reviewer wants an observed count of people entering.
- Durable medical equipment is billed as delivered to a claimant's home and the claimant says nothing arrived.
- Bills continue to arrive for a claimant who has moved away from the area where the provider operates.
What the field check covers
- Billed-date list from the client
- The dates, times and service locations the client wants tested, supplied as a simple list so no clinical or coding detail needs to change hands.
- Open or closed on billed days
- Going forward from assignment, whether the office was lit, staffed and receiving people on dates the client expects to be billed.
- Claimant whereabouts on visit dates
- Where existing or newly authorized observation placed the claimant at billed appointment times, stated with the exact hours covered and any gaps.
- Observed visit length
- Arrival and departure times of a claimant at a facility, as seen from a public area, giving the reviewer an observed duration to compare.
- Daily arrivals tally
- A count of people entering and leaving during set hours, recorded as numbers only, for comparison with the volume the client's data shows.
- Equipment delivery verification
- A voluntary interview with the claimant, at the client's request, about whether billed equipment or supplies were received, with photographs if the claimant agrees.
From request to delivered record
- RequestCall dispatch or submit the request form with the location, loss type and urgency.
- DeployDispatch assigns the nearest available licensed field investigator through the statewide network.
- DocumentPhotographs, video, measurements and factual notes are captured once the scene is safe to work.
- PreserveFiles are timestamped, organized and kept in their original form with a record of who captured them.
- ReportThe package is delivered securely to the requesting party, typically the same day.
Why the bill audit stays with the client
Deciding whether a service was coded properly, bundled correctly or supported by the chart takes clinical and coding expertise and access to records. That is the work of the carrier's bill review staff, nurse reviewers and SIU analysts. Delator's role is narrower and physical. The reviewer identifies a factual assumption inside the bill, such as presence, date, place or duration, and the investigator reports what could be observed about it.
This separation also limits what information leaves the client. An investigator can check ten billed dates knowing nothing about diagnosis or treatment. When a claimant is interviewed about deliveries or attendance, the questions concern logistics, not medical care, and the claimant is free to decline. Where a claimant is represented, the client and its counsel decide whether and how contact is made before anyone is approached.
Past dates and future dates are different problems
Bills arrive weeks after the service, so many questions concern dates already gone. For those, the investigator cannot observe anything new. What can be done is to compare the billed dates with observation already in the claim file, check publicly posted closures or schedules for that period, and interview the claimant if the client wishes. The report states clearly that these are after-the-fact checks and identifies the source of each one.
Prospective checks are stronger. If a provider bills on a regular pattern, the client can authorize observation on upcoming dates, and the investigator records who arrived and when. The resulting log can later be laid beside the bills submitted for those same dates by the client's own staff. A mismatch may reflect a clerical error, a rescheduled visit or something else. The investigator does not say which.
This service is available to insurance carriers, self-insured entities, third-party administrators and the attorneys who represent them. Delator reports facts and observed indicators; decisions on coverage, liability, settlement and any fraud referral remain with the client.
It is not offered to policyholders or claimants, and Delator does not act as a public adjuster. Policyholders and claimants can request neutral scene documentation instead.
Common questions about this service
Do you audit medical bills or billing codes?
No. Delator does not review codes, fee schedules, charts or documentation, and gives no opinion on whether a charge was proper. Investigators verify physical facts, such as whether a person or an office was where a bill implies on a given date, and report them to the client's reviewers.
Who can request billing-related field verification?
Workers' compensation carriers, self-insured employers, third-party administrators, their SIUs and attorneys representing them. The service is not available to claimants, patients or providers. The client defines the dates and locations to be checked and keeps control of the bill review itself.
What information do you need from the bills?
Only the provider name, service address, and the dates and times in question. The client can remove diagnostic and treatment details before sending anything. If the client decides to share more, it is responsible for confirming that the disclosure is properly authorized.
If observed activity does not match a bill, do you report it as fraud?
No. The report states the observation and the billed entry the client asked about, side by side. A difference can have several causes. Whether it reflects error, misunderstanding or something intentional is for the carrier, its SIU or the authorities to determine.
Available statewide, including
Every Tennessee county is covered. See the deployment map for typical response tiers by county.
Request documentation anywhere in Tennessee
Dispatch is staffed around the clock. For time-sensitive scenes, calling is fastest; the request form works for routine and scheduled assignments.