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September 9, 2019 By Asha George

CASE STUDY: Uncovering potential abusive billing

June 2019
 

During monthly monitoring of a client’s claims, the SmartLight Analytics’ team identified potential abusive billing by a licensed in-network physician who owns a family practice in Texas. The issue was identified due to an abnormal billing pattern in comparison to provider peers.  The suspicious claim pattern included repeated payments for injections without any associated drug codes stretching over a 9-month billing period.

The provider also reported an inconsistent diagnosis of chronic kidney disease for a patient, with no follow up service related to this diagnosis seen anywhere in the patient’s medical history. Additionally, this provider began billing allergy testing and antigen therapy preparation and injections for this same patient.

Records review of this provider’s billing showed references to numerous potentially excluded, unproven and non-medically necessary services including testosterone replacement therapy for male menopause, laser face lifts, laser hair and tattoo removal, laser-lipo body contouring, Botox and chemical peels. Claims not meeting medical necessity and coverage guidelines will be denied for this provider and credited back to the employer’s plan funds.

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Filed Under: costs, fraud, healthcare Tagged With: abusive billing, healthcare

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September 16, 2021 By SmartLight News Desk

SmartLight Analytics opens its new Plano, Texas, headquarters this week beginning a new chapter for the growing team of data and clinical experts working to help self-funded employers to reduce healthcare spending by identifying and eliminating fraud, waste, and abuse in healthcare claims.

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4965 Preston Park Blvd. Suite 350
Plano, TX 75093
Phone: 214-501-1046
Fax: 214-501-1208

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SmartLight Analytics combines the best inferential analytic models with a team of analytic  and clinical experts to find fraud, waste, and abuse in self-funded employer health care plan claims data.
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