Detecting Clinical Hallucinations in LVLMs via Counterfactual Visual Grounding Uncertainty

Vision-Language models (VLMs) reliability in medical diagnosis is challenged by trust-undermining hallucinations. Existing hallucination detection approaches mainly focus on identifying factual inconsistencies between generated text and reference data. While some studies analyze where models attend in images, they seldom verify whether such attention truly reflects the visual evidence supporting the generated text. To address this gap, we propose Co}unter-Evidence Verification (CoEV), a training-free plug-and-play framework that detects and corrects hallucinations through evidence-based factual consistency verification. CoEV performs bidirectional verification between textual assertions and visual evidence, testing whether each statement is supported by its corresponding evidence region, and assigns each statement into a four-quadrant diagnostic map capturing combinations of text factuality and visual grounding. CoEV detects hallucinated content and serves as a post hoc refinement tool, correcting hallucinations without retraining. Extensive experiments on four medical datasets show that CoEV combats hallucinations in VLMs.For hallucination detection, CoEV consistently outperforms existing methods, improving average PR-AUC and ROC-AUC by 3.0% and 3.9% absolute points respectively, with notable gains of up to 18.5% in specific VQA scenarios. For hallucination correction, it improves Micro-F1 by up to 12.5%, reduces hallucination rates by over 11.9% on medical report generation, and also boosts medical VQA accuracy. These results show that CoEV enables reliable detection and correction of hallucinations, providing clinicians with dependable, evidence-based cues for diagnosis. Code will be released upon acceptance.

Large vision--language models (LVLMs) demonstrate strong multimodal reasoning capabilities but remain prone to hallucination, where model predictions are not grounded in visual evidence. Existing black-box hallucination detection methods estimate uncertainty through a single consistency metric, implicitly assuming that model uncertainty can be adequately characterized by a single measure. However, hallucinations exhibit diverse manifestations of uncertainty across different behavioral probes, making a single measure insufficient to characterize their underlying behavior. We propose \emph{Unique Hallucination Pattern (UHP) Detection}, a fully black-box framework that models hallucination as a structured uncertainty pattern defined by two axes: perturbation modality (image vs.\ text) and logical polarity (a statement vs.\ its negation). Their intersection produces four complementary consistency groups that capture distinct manifestations of model uncertainty, from which both within-group and between-group features are extracted to train a lightweight classifier. Through comprehensive experiments on AMBER and PhD across three LVLMs, UHP Detection consistently outperforms prior black-box and white-box baselines, with improvements of up to $+18.72\%$ AUC-ROC and $+20.07\%$ AUC-PR over the strongest black-box methods. Extensive ablation studies demonstrate that each consistency group contributes complementary information and that their combination forms a structured hallucination pattern. Furthermore, cross-dataset evaluation shows that this learned pattern generalizes across benchmarks, indicating that hallucination behavior reflects a model-specific consistency pattern. \textbf{Code is publicly available at} https://github.com/amirezzati/uhpdet.

Large Vision-Language Models (LVLMs) often suffer from object hallucination, generating objects that are absent from the image. Prior work largely attributes this to insufficient visual attention. However, we find that both real and hallucinated objects receive equally strong visual attention in the model's mid-to-late layers, suggesting that the key issue may not be how much the model attends, but what it attends to and why. To this end, we decode the visual features of high-attention regions using Logit Lens, and observe that regions corresponding to real objects can be correctly decoded to the target object tokens, whereas those for hallucinated objects cannot. Building on this, we identify two hallucination mechanisms: (i) visual uncertainty, triggered by semantically similar or confusable regions; masking these regions eliminates the hallucination. (ii) contextual prior, triggered by strong co-occurrence priors; even when the initially attended region is masked, the hallucination persists and attention drifts to other regions. Based on these findings, we propose a simple yet effective training-free Detect-Mitigate framework comprising a Logit-Lens Consistency Check to detect hallucination and targeted remedies: High-Attention Regions Masking (HARM) for visual uncertainty hallucination, and Visual Evidence Enhanced Decoding (VEED) for contextual prior hallucination. Our approach achieves state-of-the-art results on multiple hallucination benchmarks. Code will be available.