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August 19, 2019 By Asha George

Cosmetic Surgery Is Ripe for Fraud

Multiple healthcare fraud schemes have been investigated over the years involving providers who misrepresent cosmetic procedures as medically necessary ones to increase patients and their profit. Rhinoplasty is known to be the most common procedure that is inappropriately billed to health insurance. Surgeons charge for repair of a “deviated septum” and then perform cosmetic rhinoplasty. Tummy tucks have also been billed to insurance as hernia repair. Separation of the abdominal muscles is sometimes falsely called a hernia and billed to insurance.


Any effective wasteful spend analysis should routinely conduct review of a focused sample of medical records as an identification and prevention measure. We posted last week about one case.


An example can be seen from a selected visits review ($10,000 – $30,000/per procedure): A 26-year-old female was billed for reduction mammoplasty by a Beverly Hills plastic surgeon. Services that are typically seen prior to this procedure, i.e. physical therapy for back pain or related office visits, were not seen in this member’s medical history prior to surgery.

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Filed Under: costs, healthcare Tagged With: claims, cosmetic surgery, fraud

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Inappropriate ER use has gone from serious to critical

November 1, 2021 By Franklin Baumann, MD

Correcting ER overuse has the potential for substantial cost reductions for employers and improved health outcomes for employees.

Who’s Watching the Money?

October 28, 2021 By SmartLight News Desk

Examining exactly where healthcare dollars are spent is not just a budget management or cost-saving practice for business, as plan sponsors are reminded often, it is also a fiduciary responsibility under the Employee Retirement Income Security Act (ERISA).

SmartLight Analytics opens new Plano, TX headquarters

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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SmartLight Analytics has been named finalists in D CEO Magazine Excellence in Healthcare Awards 2020 for Outstanding Service Innovation.

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