• Skip to main content
  • Skip to footer

SmartLight Analytics

Reducing healthcare costs for self-funded employers

  • The Problem
  • The Solution
    • Testimonials
  • About Us
    • Jobs at SmartLight
  • News & Blog
  • Contact

August 27, 2020 By SmartLight News Desk

In healthcare claims, does distance matter?

Can the distance between your medical provider and the lab used to process your test results tell you anything about potential fraud, waste, or abuse? In fact, it can.  

In reviewing healthcare claims, data specialists use geospatial analysis to compare distances traveled for lab services. This strategy is used in one of many inferential analysis models that is not searching for a specific medical code within claims, but uses statistics and probability to determine if an observed action differs from an expected action. This can lead to a great deal of information inside of healthcare claims.  

How? It begins when analysts calculate a mathematical score that evaluates the actual distance traveled for lab services compared to what is the expected distance. One claim reviewed by the SmartLight Analytics team expected a distance of seven miles for lab work, the actual distance was two miles from the provider. That claim was then compared to another claim where the expected distance for lab work was 10 miles, but the actual distance was 2,976 miles. This drastically different mileage might indicate a pass-through billing lab scheme and at the very least requires further investigation.  

When working with businesses across the country, data analysts have found instances where providers have sent lab work or even bill for services across thousands of miles and sometimes even across state lines unnecessarily. Geospatial analysis has also been used to find claims where services were billed hundreds of miles from where the member employee could have reasonably been assumed to be that day. For example, a claim was flagged because it contained billing for an office visit to a nurse practitioner on a specific day as well as billing for tests conducted at a rural hospital 350 miles away on the same day. To believe this occurred as billed, the member would have had to travel more than 350 miles from his or her home on the same day for these tests. What likely happened was that the member saw the provider near home and the provider sent the claims to the rural hospital for billing. Such claims would then be investigated further to determine whether or not it was fraud or just an unusual case or a very sick patient who needed a specialized service. 

Geospatial analysis is just one of 40 different proprietary models used by SmartLight analysts to find fraud, waste, and abuse within healthcare claims.  

Share this:

  • Twitter
  • Facebook
  • LinkedIn
  • Print

Filed Under: Analytics, costs, fraud, healthcare

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

SmartLight Analytics named “Outstanding Service Innovation” winner in the D CEO 2020 Excellence in Healthcare awards

December 3, 2020 By SmartLight News Desk

SmartLight Analytics named 2020 Excellence in Healthcare Award winner for Outstanding Service Innovation by D Magazine.

SmartLight News Desk

SmartLight Analytics Achieves HIPAA Compliance with Compliancy Group

June 3, 2020 By SmartLight News Desk

SmartLight Analytics earned HIPAA compliance regulation by completing Compliancy Group’s proprietary 6-Stage HIPAA Risk Analysis & remediation process.

CoronavirusAsha George

Mitigating costs and avoiding fraud, waste & abuse in a pandemic

April 1, 2020 By Asha George

There is no question employers across the nation with self-funded healthcare plans will see increases in the cost of covering sick employees during the COVID-19 pandemic. What they want to avoid is increases due to fraud, waste and abuse. Existing areas of vulnerability in our healthcare system could be ripe for additional fraud and abuse when the country is in crisis mode.  With reduced oversight to improve accessibility to treatment during the pandemic, fraudulent billing could slip through easier than ever. Bad actors – those already […]

SmartLight News Desk

Finding wasteful spending in healthcare: A Female Founder’s Journey

March 3, 2020 By SmartLight News Desk

A study released late last year estimated between $760 billion and $935 billion spent on healthcare in the U.S. is waste. That’s 25% of the total costs of healthcare according to estimates published on JAMA Network.1 Further broken down, the study found between $58.5 billion and $83.9 billion are a result of fraud and abuse, […]

Footer

14785 Preston Road, Suite 550, Dallas, TX 75254
(469) 941-6221 • info@smartlightanalytics.com
FOLLOW US:
  • The Problem
  • The Solution
  • About Us
  • News & Blog
  • Contact

Copyright © 2021

Close