These Ghosts Don’t Stand a Chance!

Phantom DME Investigation Skill Building

DME phantom supplier schemes continue to significantly impact government and commercial health plans. These schemes represent a paradigm shift: bad actors purchase existing DME suppliers and leverage established contracts to rapidly submit high volumes of claims, often generating substantial payments before traditional safeguards can intervene.

Elevance Health’s Special Investigations Unit (SIU) has developed proactive, data-driven investigative strategies to combat this evolving threat. This session will examine the anatomy of the scheme, including spike analysis, billing pattern recognition, modifier and diagnosis discrepancies, and provider connectivity analysis. Attendees will also learn practical tools such as stop payment processes, pre-payment review implementation, reverse image searches, and cross-plan collaboration techniques.

Through real-world case studies, the presenters will demonstrate how early detection and coordinated intervention can significantly reduce losses and prevent future fraud exposure.

Learning Objectives

After completing this session, participants will be able to:

• Describe the evolving structure and operational model of DME phantom supplier schemes, including the acquisition of existing suppliers and high-volume billing tactics.
• Identify key data indicators and billing patterns associated with phantom DME suppliers, including spike analysis, diagnosis and modifier discrepancies, and recurring HCPCS code combinations.
• Apply proactive investigative strategies — such as pre-payment review, stop payment processes, provider connectivity analysis, and cross-organizational collaboration — to detect and mitigate losses from DME phantom supplier schemes.

SpeakerS:

Wayne Fisher, MBA, AHFI, CFE
Manager, Special Investigations Unit
Elevance Health, Inc.

Shannon Zabo, MPA, AHFI, CPC
Investigator Lead, Special Investigations Unit
Elevance Health, Inc.