CLM-2026-084721
Critical RiskFlaggedPatient
Dorothea Harrington
PAT-39201
Provider
Riverside Orthopedic Clinic
NPI: 1234567890
Service Date
05/22/2026
Submitted: 05/23/2026
Billed Amount
$42,800
Allowed: $18,200
Total Billed
$42,800
4 procedure lines
Medicare Allowed
$18,200
CMS fee schedule
Overbilling Variance
$24,600
+135% above allowed
Fraud Exposure Est.
$17,712
72% recovery probability
ML Risk Breakdown
Critical Risk
Exceeds threshold by 14 pts. Composite score from 4 triggered ML rules.
Recommended Actions
2 urgentObtain operative notes and pre-auth documentation from Riverside Orthopedic Clinic within 5 business days.
PRV-10482 meets threshold for full billing audit — 18 flagged claims, 6 confirmed fraud in 90 days.
Verify PAT-39201 prior treatment history to confirm surgical necessity for CPT 27447.
Payment hold active — $0 disbursed. Maintain hold until investigation concludes.
Procedure Lines
Diagnosis & Clinical Context
Primary Diagnosis
M17.11
Primary osteoarthritis, right knee
Service Type
Inpatient Surgical
Orthopedic — Major Joint
Place of Service
POS 21
Inpatient Hospital
Prior Auth
Not Verified
No pre-auth on record
Payer
Medicare Part B
INS-BCB-8820041
Rendering Provider
Dr. R. Patel, MD
NPI: 1234567890
Patient
Name
Dorothea Harrington
Patient ID
PAT-39201
Date of Birth
03/14/1958
Insurer ID
INS-BCB-8820041
Provider
HIGH RISKName
Riverside Orthopedic Clinic
Provider ID
PRV-10482
NPI
1234567890
Specialty
Orthopedic Surgery
Network avg: 18.4%
Investigation
Assigned To
Marcus Aldridge
Flagged
05/24/2026 08:14
Investigation Status
Awaiting Records
SLA Deadline
05/31/2026