SmartLight Analytics

Reducing healthcare costs for self-funded employers

SmartLight News Desk

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“Rehab resorts” recruit patients

Fraudulent claims from rehab facilities that function more as resorts, recruiting patients and even paying commissions for admissions, seems to be a growing trend.

Our past findings have been consistent with recruiting and clearinghouse practices well documented among some rehab centers. In such centers, patient recruiters typically receive payment from the rehab centers for each patient they obtain that generates revenue. Predatory marketing practices often involve a misrepresentation of the services offered and the auctioning of patients through clearinghouses. The clearinghouses route patients to call centers, and once the patient’s insurance is verified the clearing centers act as brokers auctioning off the patients to the highest bidding rehab centers.

“Rehab operators have told the Southern California News Group (which investigated the addiction industry in 2017) that they know it’s wrong to offer money to middlemen in exchange for well-insured patients, but that the practice is so ubiquitous in California they’d have no patients at all if they stuck to the high ground,” according to the piece titled, “Rehab patient brokering is rampant, but it’s hard to stop, industry says,” published in the Orange County Register on May 30, 2018, and written by Teri Sforza, Tony Saavedra and Scott Schewebke.

“Addicts start to see their insurance cards as credit cards, operators said, demanding better food, cell phones, even cash from providers in exchange for staying in treatment. If the provider doesn’t deliver, the addict bolts to a different treatment center that will give him more of what he wants,” the article stated.

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SmartLight Analytics grew out of a desire to take meaningful action on rising healthcare costs

In August 2016, SmartLight Analytics was founded out of a desire to help employers deal with the rising cost of healthcare and make an impact that would not only help big companies but thousands of their employees as well.

Employee healthcare costs are expected to top $15,000 per employee in 2020, according to research from the National Business Group on Health.

SmartLight Analytics is focused solely on reducing year-over-year medical spend for self-funded employers. Founder and CEO Asha George headed up the Payment Integrity departments inside various large insurance carriers for decades before forming SmartLight Analytics. SmartLight was created because she saw the need for more independent, pro-active intervention in reducing unnecessary healthcare spend. 

“The American healthcare system has become increasingly more elaborate and difficult to navigate over the past several decades. Within this environment of complexity and rising costs, over 95% of employers are now funding their own employees’ healthcare,” George explained, adding that industry experts estimate billions of dollars are leaking out of the system with no measurable improvement in patient health.

To significantly reduce this waste, SmartLight Analytics, LLC was formed by a group of industry insiders including George and her co-founder: Chief Medical Officer Dr. Franklin Baumman, a surgeon who spent 11 years as a medical director for UnitedHealthcare, the largest insurance carrier in the country.  

“We wanted to make a meaningful impact on the rising cost of healthcare,” George said.

With this end in mind, SmartLight uses statistical, clinical, and claims expertise to deliver the most complete cost reduction solution directly to the actual stakeholders – self-funded employers. Since processing claims is outside the core competency of most employers, patterns of error often go unnoticed and result in the unnecessary spend of health plan dollars. SmartLight delivers a low-touch, high-impact solution to self-funded employers.

Other organizations with the similar vision of reducing commercial healthcare costs, are primarily using member pricing transparency tools, allowing members access to pricing options for specific services. Whereas SmartLight is a comprehensive solution that works on identifying and resolving issues directly from the client’s plan funds, George explained. “SmartLight identifies wastes, coordinates with the employer’s claims administrator to prevent future waste and, most importantly, ensures that offsets and denials are credited back to the health plan.”

“I’m passionate about making a meaningful impact in this space,” George said. “Insurance carriers, in the role of third-party administrators, do their best to manage the waste in the system while processing claims, but we have, without exception, reduced spend by an additional 3-5% for our customers. We use statistical, clinical and data expertise developed over decades of experience to deliver the most effective cost-reduction solution available in the market, customized to your unique population.”

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Phantom billing: Can you spot it in your claims?

Three seemingly unrelated imaging providers based in FL were identified in a self-funded employer’s medical claims for what was later verified as phantom billing.


The utilization patterns seen in paid claims history for an employee and his wife indicated a strong probability of “phantom” billing – billing for services never performed. Phantom billing typically involves setting up fake corporation(s) with the intent of billing non-rendered services. The individuals involved with the phantom corporations will then recruit patients by offering them an incentive in exchange for allowing their insurance to be billed.

Patients will also be offered incentives to recruit other members of the same insurance plan. Phantom providers start and stop billing within a short period of time in order to avoid detection.

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City of Fort Worth engages SmartLight to reduce healthcare spend

FORT WORTH, TX – The Dallas-based healthcare analytics firm, SmartLight Analytics, will soon begin an initial assessment of the City of Fort Worth’s employee healthcare claims data in an effort to further reduce the city’s healthcare spending costs, which in 2017 went $15.2 million over budget.

“The City of Fort Worth is looking at ways to further reduce their employee healthcare spend because they have a finite budget and, when it comes to managing the rising cost of healthcare,  they have to continue to look for ways to contain those costs,” said Asha George, CEO and co-founder of SmartLight Analytics. “The city has reduced spending in the last year and gotten costs under control with some innovative initiatives such as on-site clinics. We will work to help them realize further savings on healthcare costs by identifying wasteful spending and errors currently occurring in their employee healthcare claims.”

The city’s budget saw a dramatic turn-around in 2018 when the cost for providing healthcare for more than 6,000 employees plus dependents came in under budget. As the city, like many other municipalities and businesses, continue to face the uphill battle of rising healthcare costs, officials engaged with SmartLight Analytics to look at additional innovative means to keep costs under control moving forward.

George said SmartLight’s role will be to analyze two to three years of healthcare claims from the city to find waste — such as duplication of services, unintentional billing errors, and intentional fraud, waste or abuse — and take action to eliminate this unnecessary spend from the city’s employee healthcare costs.

“We’re in the process of getting historical data to run through our inferential analytical models now,” George explained.

The SmartLight Analytics clinical team of medical coding specialists led by board-certified physicians will review the claims identified by analytic models as either having waste, duplications, errors or other issues that could be costing the city unnecessary dollars. The initial report to the city will show officials exactly where there was wasteful spending or other errors or claims issues. SmartLight’s clinical team would then work with the city’s insurance carrier to eliminate the wasteful claims before they are paid again.

George said she expects SmartLight to identify as much as a 5% savings on the healthcare spend through its analytical analysis. The process will take rough 8-10 weeks to complete once SmartLight receives the data, both medical and pharmacy claims. The city could see its first reports in late September.

 “In the end, if we’ve done our job, as we have for other customers,” George said, “we can reduce the city’s spending, and eventually, the out of pocket expenses for employees without reducing benefits.”

SmartLight was recommended to the Fort Worth Human Resources leadership by another customer, Dean Foods, which has worked with SmartLight since 2016. Dean Foods executives said the process worked for the company in reducing healthcare costs for their 16,000 employees.

“The process of working with SmartLight Analytics was easy for us,” said Mike Adams, Vice President of Benefits & HR systems of Dean Foods, a multi-billion-dollar food and beverage company. “Asha George, CEO of SmartLight, established a good working relationship with our medical claims processor. We are extremely happy with the results. They identified claims with waste and fraud, researched and recovered those costs and had it credited back to us.”