SmartLight Analytics, LLC blog

Autism Therapy: From 63% Growth to $5.5M in Claim Anomalies: How SmartLight Identifies the Risks Before They Compound

franjo@loncomconsulting.com (Test Author) — Thu, 13 Aug 2026 09:52:24 GMT

Autism therapy has become the fastest-growing category in covered claims—and the numbers are striking. SmartLight Analytics’ review of client claims processed found that autistic disorder claims surged 63.2% between 2023 and 2025, outpacing every other covered category including routine adult health exams and chemotherapy.¹

Fueling the claims growth is the rise in diagnoses, coupled with therapy coverage expansion across Medicaid and commercial plans. As of April 2025, 1 in every 31 Americans is diagnosed with autism, up from 1 in 150 people before 2000. Every state Medicaid program now covers autism services. Self-funded plans that try to rein in costs by tightening utilization controls are bound by parity laws such as MHPAEA.²

Self-funded plan sponsors should monitor their utilization patterns and network strength to ensure their members have access to the services they need.

COVERED SERVICES WITH THE GREATEST UTILIZATION GROWTH

2023 – 2025
Rank	Diagnostic Code	Description	% Change
1	F840	Autistic Disorder	63.2%
2	F411	Anxiety Disorder	56.0%
3	I480	Paroxysmal AFIB	53.8%
4	F332	Major Depressive Disorder	45.5%
5	C61	Malignant Prostate Neoplasm	35.4%
6	Z0000	General Adult Health Exam	32.9%
7	G4733	Obstructive Sleep Apnea	27.9%
8	Z5112	Antineoplastic Immunotherapy	23.3%
9	Z1211	Colonoscopy	22.9%
10	Z5111	Antineoplastic Chemotherapy	15.8%

RAPID PROVIDER GROWTH IS DRIVING UTILIZATION—AND SCRUTINY

Applied Behavioral Analysis (ABA) is the most common therapy approach for autism disorders, applying the principles of behavior change to specific techniques and tasks. To meet rising demand for ABA therapy, there has been a 457% increase in registered behavioral technicians since 2019, now totaling roughly 535,000 nationally. These technicians work with their patients to practice common life skills including household chores, communication, and social interaction.³

But the rapid growth in the technician workforce has outpaced oversight—and that gap is showing up in claims data.

Based on SmartLight Analytics’ review of claims data across a subset of self-funded employer groups, representing average annual covered lives of 872,563 (2023), 1,007,608 (2024), and 1,035,245 (2025).

Where utilization climbs this fast, billing scrutiny must follow.

A Wall Street Journal investigation published in March 2026 uncovered ABA therapy providers billing Medicaid as much as $340,000 per patient per year. A subsequent Journal article published in June 2026 reported that autism therapy spending for a coalition of approximately 40 large employers covering 3.5 million lives doubled between 2021 and 2025, reaching $108 million. One major national insurer reported a 300% increase in investigations for likely fraud and abusive billing by autism-therapy providers between 2024 and 2025.^3,4

With this growth has come an increase in suspect activity and billing practices—including providers changing names and billing identifiers to avoid detection, and billing for more services than rendered.

Through monitoring of self-funded group claims, SmartLight identified several providers with questionable billing practices. One practice established nine LLCs, each reflecting similar billing patterns, including excessive per-visit payments, inconsistent alignment with service units, and frequent use of lower-credentialing modifiers. For one self-funded group, SmartLight performed a historical claims review through 2024 and early 2025, finding that this practice received full reimbursement of 100% of billed charges, regardless of treatment volume or duration, resulting in paid amounts exceeding $5.5M across 950 claims.⁵

Below are some of the findings in the historical claims data review:

Billing rates across the practice’s nine affiliated LLCs vs. median in-network rates, based on SmartLight Analytics review of 950 claims.

CPT Code	Description	Avg Amount Paid	Median In-Network Rate	% Over INN Rate
97153	Adaptive Behavior Treatment by Protocol, ea 15 min	$5,175	$273	1,795%
97155	Adaptive Behavior Treatment with Protocol Modification, ea 15 min	$3,583	$171	1,995%

The carrier has since taken corrective action.

PLAN PROTECTION

Billing patterns like these rarely surface through routine claims processing—they require dedicated, ongoing anomaly detection across the full claims history. SmartLight’s ongoing monitoring and clinical investigation can quickly identify these suspect billing patterns and irregularities before they compound.

Early claim anomaly detection matters. When suspect billing is referred, your carriers can take action to protect impacted members and help connect them with quality providers who can deliver the care they need.

1.SmartLight Analytics internal data, May 2026.

2.Cato Institute, April 2, 2026.

3.Christopher Weaver and Anna Wilde Mathews, “The Autism-Therapy Business Is Booming—and So Is the Billing Abuse,” The Wall Street Journal, June 1, 2026.

4.Christopher Weaver and Anna Wilde Mathews, “She Charged $29 Million to Treat Just 84 Kids. The Boom in Autism Therapy Is Medicaid’s Fastest-Growing Jackpot,” The Wall Street Journal, March 10, 2026.

5.SmartLight Analytics review of client’s retrospective claims processed, November 2025.

Payment Integrity Programs: What Every Self-Funded Employer Needs to Know

franjo@loncomconsulting.com (Test Author) — Thu, 13 Aug 2026 09:51:57 GMT

PAYMENT INTEGRITY PROGRAMS: WHAT EVERY SELF-FUNDED EMPLOYER NEEDS TO KNOW

Healthcare claims are among the most complex financial transactions in any organization’s budget — and for self-funded employers, the stakes are high. Carriers work hard to adjudicate claims accurately, but the sheer volume and complexity of modern claims processing means errors are inevitable. It is estimated that for every $100,000,000 in health spend, overpayments translate to $5,000,000 to $10,000,000+ in waste.¹

To address this, carriers have payment integrity programs designed to identify and recover overpayments. These programs go beyond routine random sample audits, which typically capture less than 0.5% of actual claim errors, conducting deeper reviews of claims history to surface additional overpayments. When an error is identified and corrected, carriers take a percentage of the recovered or prevented amount as a shared savings fee and return the remaining balance to the employer group. Fees typically range from 25-50% of the calculated savings amount.

These programs serve an important purpose, and when structured properly, they can meaningfully reduce costs for plan sponsors. However, plan sponsors should understand exactly how these programs work—and what questions to ask—to ensure savings are calculated correctly and fees are assessed only where appropriate.

DEFINING THE SCOPE FOR SHARED SAVINGS

Claims are complicated and can be processed through multiple sequences. As a result, savings may have been reversed and inadvertently not reversed on your shared savings invoice.

Each time a claim is adjusted that is part of these payment integrity programs, it should be tracked to determine if the identified issue should be captured under core administrative claims processing functions or if it reflects a broader issue related to provider submissions.

Contract terms should define how savings will be calculated. For example, savings should be calculated using the “pre-allowed” total as defined by your plan design rather than billed charges. Engage your legal team at contract renewal to ensure you have clarity on your program, ensuring reversal rationale alignment.

CASE EXAMPLE: SAVINGS CALCULATION ERROR

A provider submitted a duplicate bill for processing. Through the post-payment claims review process, the duplicate billing was identified. However, the claims administrator applied the procedure code (95165) instead of the billed amount ($240). As a result, the carrier identified the total savings of $95,165 and collected their percentage.²

SmartLight evaluated the claims details and notified the carrier of the coding error. The carrier agreed this was an administrative error, and returned their shared savings fee, $28,550, to the client.

IDENTIFYING AND CORRECTING THE ROOT CAUSE

Since payment integrity programs are paid at a contingency, carriers may have little incentive to correct the root cause of the issue, and ongoing issues may remain unresolved.

For example, if a provider continues to misbill a modifier code, the carrier should provide education on how that code should be billed instead of collecting revenue in perpetuity. If the provider continues to miscode, the plan sponsor may request pre-payment flags be placed on all of their billed services.

Plan sponsors should hold their carriers accountable for root cause resolution. When enrolled in a Payment Integrity program, the plan should request all data that substantiates the carrier’s evidence that fees are being reduced because the root cause has been resolved.

PROTECTING YOUR PLAN

Self-funded employers carry a fiduciary responsibility to their plan members — and that responsibility doesn’t get delegated away when they sign an administrative services agreement. Employers who want genuine protection should carefully review contract terms and ensure transparent reporting, independent oversight, and audit rights – not simply accept what carriers choose to report.

The bottom line: payment integrity should be a win for the plan—and not just the carrier.

SmartLight Analytics serves as your claims integrity advocate, fighting for every dollar in waste returned to your bottom line.

SMARTLIGHTANALYTICS.COM

INFO@SMARTLIGHTANALYTICS.COM

1. SmartLight internal data; American Medical Association. Per the AMA, more than 20% of medical claims contain errors resulting in billions in annual overpayments.

2. SmartLight Analytics payment integrity program analysis of fees assessed between August 2023 and January 2025.

Why Fortune 500 Companies Can No Longer Ignore Independent Oversight of Healthcare Expenses

franjo@loncomconsulting.com (Test Author) — Thu, 13 Aug 2026 09:39:26 GMT

A RESPONSE TO STATE FINANCIAL OFFICERS’ CALL TO ACTION

State Financial Officers across the United States have formally urged Fortune 500 companies to conduct rigorous payment integrity reviews of their healthcare spending. These officers, acting as fiduciaries for public investment funds, have reframed healthcare overspending from an HR issue to a direct threat to shareholders. Their goal is clear: control costs, mitigate risk, and protect shareholder value.¹

SmartLight clients can respond with confidence to the State Financial Officers’ call to action.

THE CASE FOR INDEPENDENT MONITORING

Employer healthcare spending in the United States is projected to reach $1.83 trillion this year. This massive expenditure demands the same financial discipline and independent scrutiny applied to any other major corporate cost.²

The letter from the State Financial Officers implies the conventional approach—relying on carriers, third-party administrators, and pharmacy benefit managers to audit their own billing—is fundamentally flawed.

THE CARRIER CONFLICT OF INTEREST

- Revenue Risk: When carriers identify and reimburse plans for overpayments, they often reduce their own revenue streams.

- Ineffective Audits: Random, self-directed “spot checks” frequently miss billing anomalies, duplicate payments, deviations from contracted rates, and cannot identify systemic payment errors.

- Flawed Incentives: Payment integrity “shared savings” programs are often designed to cost plan sponsors more by paying carriers to fix their own billing mistakes, and plan sponsors are paying twice for services typically included in core administrative services.

These systemic flaws drive up costs and liability for employers, eroding shareholder value.

Independent, continuous oversight is a best practice—and a fiduciary imperative.

THE SMARTLIGHT ANALYTICS APPROACH

SmartLight Analytics partners with the nation’s largest employers to provide continuous, independent claims integrity review and advocacy.

- 100% Claims Analysis: SmartLight analyzes every medical, pharmacy, and dental claim on a continuous basis. This eliminates the sampling gaps in traditional audits, preventing small errors from turning into million-dollar losses over time.

- Proprietary Detection Systems: The SmartLight platform leverages proprietary models to identify payment anomalies across complex claims datasets.

- Clinical and Investigative Validation: Flagged issues are reviewed by clinical and investigative teams that validate accuracy against your specific contracts. SmartLight claims advocates then work directly with carriers to fix root causes, not just isolated incidents.

MEASURABLE FINANCIAL RECOVERY

The math is compelling. SmartLight clients consistently recover ~3–5% of total health spending, returning those funds to the bottom line.

THE COST OF INACTION

Organizations that delay face compounding risks: continued overspending and potential regulatory scrutiny. Those that implement independent healthcare expense monitoring now will be better positioned ahead of emerging compliance requirements and are better prepared to defend their fiduciary practices to investors, boards, and regulators.

SmartLight Analytics is your claims integrity advocate, delivering independent analysis, actionable intelligence, and measurable savings.

PROTECT YOUR SHAREHOLDER VALUE TODAY

www.smartlightanalytics.com | info@smartlightanalytics.com

¹ National Association of State Auditors, Comptrollers and Treasurers (NASACT) / State Financial Officers Foundation. Letter to Fortune 500 Chief Financial Officers regarding healthcare payment integrity. December 2024.

² Centers for Medicare & Medicaid Services (CMS). (2026). National Health Expenditure Projections 2024-2033: Forecast Summary. Office of the Actuary.