EUR 2.5m+ saved annually as unnecessary knee and hip procedures challenged across an entire insurer portfolio

Case 4 · Policy Level · Southern Europe

WHERE WE STARTED

A Southern European health insurer was processing high volumes of orthopedic claims — primarily knee and hip replacements — for invasive procedures that, when measured against current clinical guidelines, were being performed without adequate indication. The behaviour was pervasive across multiple providers — not a single bad actor, but a systemic pattern that the insurer had come to treat as normal.

THE CHALLENGE

Because the over-treatment was widespread, it had become invisible. The insurer’s claims team had no frame of reference that said this rate of invasive orthopedic procedures was abnormal — it was just what claims looked like. Individual clinical reviewers couldn’t easily tell whether a deviation from a treatment pathway was clinically justified or simply habitual.

What had already been tried:

Standard rules engines check for explicit exclusions and duplicate claims — they don’t assess whether a procedure is appropriate given a patient’s age, trauma history, and case mix. The insurer had considered a provider-by-provider audit but lacked the analytical baseline to distinguish genuine outliers from average behaviour that was itself the problem. The provider community also proved difficult to engage directly — any challenge without data would be dismissed.

HOW KIRONTECH FOUND IT

HIP compared each patient’s treatment journey against recommended clinical pathways, adjusting for age, presence of trauma, and case mix.
Invasive procedures were flagged where performed against current guidelines — not as exceptions, but as a pervasive pattern across providers.
A behavioural algorithm aggregated the individual flags to identify which providers and policy segments were driving the most significant deviation from expected care.
The scale of the behaviour was sufficient to escalate from individual provider review to a portfolio-level intervention.

Insurer challenge

Outcome & impact

The behaviour was so widespread it had become the baseline — no internal reference point existed to flag it as abnormal. Individual rules engines could only see what was explicitly excluded, not what was clinically inappropriate relative to patient need. The provider community was difficult to engage — any challenge without hard benchmark data would fail.

Rather than confronting providers directly, the insurer built a stronger pre-authorisation framework and case management capability — changing what would be authorised before it reached the provider. Unnecessary invasive treatments declined at point of request rather than audited post-payment. Savings of EUR 2.5m+ per annum achieved through pathway changes. Clinical directors began requesting the benchmark data to use in their own provider conversations.

WHAT CHANGED

This case shifted the insurer’s relationship with its own clinical process. Recognising that direct provider challenge was unlikely to succeed, the team focused on what they could control: what they would authorise, and under what conditions. Clinical directors began requesting the pathway benchmark data to use in their own provider conversations — the analytics that started as a fraud detection tool became part of the insurer’s clinical governance framework.

THE RESULT

Significant savings of over EUR 2.5m per annum achieved. New pre-authorisation framework and case management pathways adopted across the portfolio. Unnecessary invasive treatments declined at point of request rather than audited post-payment.

EUR 2.5m+ saved annually as unnecessary knee and hip procedures challenged across an entire insurer portfolio

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