Healthcare Billing Fraud: Key Steps for Contact Centers

Contact centers that partner with healthcare providers play a critical role: They verify patient information, process payments, and relay sensitive medical details.

However, these daily interactions can create opportunities for billing fraud if not handled with proper security protocols.

Fraudsters who exploit contact center vulnerabilities can submit false claims, misuse personal data, and manipulate authentication processes, undermining trust between healthcare organizations and their patients.

In this article, we’ll examine key challenges around healthcare billing fraud and share methods contact centers can use to mitigate risks, particularly through strategies like voice authentication and advanced fraud detection.

Understanding billing fraud in healthcare

Billing fraud typically occurs when someone submits claims for services that were never rendered, misrepresents patient details, or inflates costs.

Although providers are often involved, fraudsters can also gain access through contact centers, especially those representing multiple practices or hospital networks.

Contact centers sit at the front lines. Representatives routinely confirm identities, process payments, and discuss confidential medical details over the phone. Without proper safeguards, these exchanges can jeopardize the patient experience and expose both providers and contact centers to identity theft schemes and billing fraud.

Impact of billing fraud in healthcare

Billing fraud doesn’t just harm healthcare organizations—it also impacts the contact centers that serve them. While the exact cost of billing fraud is difficult to determine, it is unquestionably substantial. Key data points include:

When billing fraud involves misrepresenting patient identities, it can result in canceled services, retracted payments, and insurance complications. This creates friction between the contact center, healthcare provider, and patient, underscoring the need for strong security measures.

Learn more: See our guide on improving healthcare contact centers for patient satisfaction by balancing smooth customer experiences with adequate security.

Types of healthcare billing fraud

Fraud can arise from several tactics, including misuse of funds, inflated claims, or impersonation. As a contact center managing multiple provider accounts, it’s vital to recognize these patterns.

Impersonating patients to negotiate bills

Fraudsters often impersonate patients, sometimes using voice phishing or deepfake technology, to manipulate billing processes. They may call contact centers to lower bills, request inaccurate discounts, or intercept reimbursement checks.

A 2023 Federal Trade Commission report identified imposter scams as the top fraud category, accounting for $2.7 billion in reported losses—highlighting the growing threat of voice-based impersonation.

Failing to collect copays or deductibles

From a contact center perspective, an overlooked or waived copay can indicate a hidden agenda—either intentional fraud or incomplete claim submissions.

Over time, these discrepancies can surface during audits, jeopardizing both healthcare providers’ reimbursement status and the contact center’s credibility and client relationships.

Filing claims under non-reimbursable procedure codes

Fraudsters may submit claims under alternative or higher-paying codes for services that were never performed, or systematically “upcode” claims to increase reimbursement.

If your agents process these claims without sufficient oversight, your contact center could inadvertently become a channel for fraudulent billing.

Real-life cases of billing fraud

Billing fraud mitigation strategies

Because contact centers are often the first touchpoint for billing interactions, several steps can help minimize fraud exposure.

Voice authentication

Implementing voice authentication—also known as voice analysis—can help distinguish legitimate callers from potential fraudsters.

Unlike security questions, which can be compromised through data breaches, voice authentication detects voice characteristics that are difficult to spoof.

Further reading:

Integrating automation for fraud detection

Automation adds another critical layer for spotting billing inconsistencies and potential abuse. Automated fraud detection tools can flag repeated claims for the same patient or mismatches between diagnosis codes and treatment logs.

Automation allows your team to focus on confirmed red flags rather than manually reviewing every claim.

For more information on how advanced solutions help protect against emerging threats, check out these facts on BlackCat ransomware for healthcare protection.

Conducting independent reviews and audits

Regular audits—either internal or conducted by third parties—are vital to uncover issues that might otherwise go unnoticed. Focus areas include:

Mitigating billing fraud in healthcare contact centers with Pindrop^® Solutions

Pindrop offers solutions designed to help safeguard healthcare contact centers against billing fraud. Here’s how each product can support healthcare contact center operations:

Discover more about how Pindrop^® safeguards healthcare contact centers—delivering stronger security, smoother authentication, and a better caller experience.