Fraud Detection Dashboard

4 CRITICAL

Last updated: 05/30/2026 11:53 AM•● Live

Estimated Fraud Exposure

$2.84M

Across 47 critical + high-risk claims this period

+18.4%vs. last 30 days

Unreviewed

$1.62M

Under Review

$847K

Confirmed

$374K

Flagged Claims Today

29

Of 1,847 claims processed

+5vs. yesterday
9 Critical12 High8 Med

Detection Precision

73.2%

Claims confirmed as fraud / total flagged

+2.1%vs. last month

Avg. Resolution Time

4.7d

Days from flag to close

-0.8dimprovement

Duplicate Billing Rate

8.3%

Of all flagged claims this month

+1.2%vs. last month

Upcoding Incidence

34.1%

Largest fraud pattern this period

+4.7%vs. last month

Daily Flagged Claim Volume

May 2026 — flagged vs. confirmed vs. cleared

Last 30 days

Investigation Activity

Today

CLM-2026-079882 escalated to senior review

Marcus Aldridge·11:42 AM

CLM-2026-078341 confirmed as Phantom Billing fraud

James Whitmore·10:18 AM

New critical claim CLM-2026-084721 auto-flagged by FR-042

System·08:14 AM

CLM-2026-074112 cleared — duplicate entry resolved

Priya Venkatesh·Yesterday

CLM-2026-083109 assigned to Priya Venkatesh

Marcus Aldridge·Yesterday

Note added on CLM-2026-075503 — provider billing history reviewed

Priya Venkatesh·May 28
12 claims
Claim ID
Patient
Provider
Service Date
CPT Code
Billed Amt
Risk Score
Anomaly
Status
CLM-2026-084721

Dorothea Harrington

PAT-39201

Riverside Orthopedic Clinic

PRV-10482

05/22/202627447

$42,800

Allowed: $18,200

94
Critical
UpcodingFlagged
CLM-2026-078341

Amara Diallo

PAT-62104

Meridian Pain Management

PRV-55901

05/14/202664483

$22,300

Allowed: $8,600

91
Critical
Phantom BillingConfirmed Fraud
CLM-2026-083109

Reginald Okonkwo

PAT-44822

Summit Neurology Associates

PRV-20871

05/19/202695819

$8,900

Allowed: $3,100

88
Critical
Duplicate BillingUnder Review
CLM-2026-070021

Beatrice Nakamura

PAT-30572

Riverside Orthopedic Clinic

PRV-10482

05/02/202627130

$38,900

Allowed: $22,100

85
Critical
UpcodingConfirmed Fraud
CLM-2026-079882

Theodore Blackwell

PAT-28819

Advanced Cardiology Group

PRV-44512

05/15/202693306

$14,600

Allowed: $9,200

82
Critical
UnbundlingEscalated
CLM-2026-071440

Alejandro Fuentes-Mora

PAT-20481

Coastal Oncology Institute

PRV-10482

05/04/202696413

$18,700

Allowed: $14,200

79
High
Unlicensed ProviderEscalated
CLM-2026-081445

Luz Castellanos-Rivera

PAT-51037

Northgate Family Medicine

PRV-33104

05/18/202699215

$4,200

Allowed: $2,800

76
High
UpcodingFlagged
CLM-2026-075503

Constance Mwangi

PAT-84901

Harbor Surgical Center

PRV-72389

05/10/202647562

$31,400

Allowed: $19,800

71
High
UpcodingUnder Review
CLM-2026-072887

Ingrid Thorvaldsen

PAT-10293

Pinnacle Physical Therapy

PRV-94128

05/06/202697110

$3,600

Allowed: $2,100

63
High
Excessive UnitsFlagged
CLM-2026-076920

Vladislav Petrov

PAT-73348

Eastside Dermatology

PRV-61720

05/12/202617311

$6,800

Allowed: $5,100

58
Medium
Excessive UnitsFlagged
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