23,635 spinal patients analysed: impossible procedure combinations and unsafe device use identified — public inquiry upheld findings

Case 6  ·  Country Level  ·  Australia

WHERE WE STARTED

Referred via a client partner, Kirontech was engaged to assist ABC’s Four Corners documentary programme with analysis of spinal treatment data in Australia. Data from 23,635 patients who had received spinal treatments was imported into HIP and analysed using Medicare billing rules alongside bespoke analytical models built specifically for this project.

THE CHALLENGE

Both Medicare and private insurers were paying spinal treatment claims on trust, with insufficient capability to validate whether the procedures billed were clinically appropriate, physically possible, or compliant with Medicare rules. The problem was not isolated — it was endemic to the system.

What had already been tried:

Medicare’s standard validation checked for billing rule compliance at a basic level but had no mechanism to assess whether procedure combinations were anatomically possible, whether devices were being used appropriately, or whether the volume and nature of interventions posed patient safety risks. Private insurers were in the same position — paying on trust with no benchmark for what appropriate spinal care should look like at a population level.

HOW KIRONTECH FOUND IT

• 23,635 patients’ spinal treatment records were imported into HIP and analysed against Medicare billing rules.
• HIP identified impossible procedure combinations — procedures billed together that cannot physically be performed in the same surgical session.
• Non-compliant billing was detected, including supplements billed for major surgery when the procedure had not been classified as major.
• Strong evidence of inappropriate procedures and interventions was identified, some posing direct patient safety risks.
• Devices used in ways inconsistent with their approved clinical indications were flagged — the findings informed a regulatory review that subsequently led to specific devices being banned or restricted.

WHAT CHANGED

The consequences of this case extended well beyond any single insurer. Regulatory action, device restrictions, and criminal prosecutions followed. For the first time, Australia had a data-backed picture of what was happening to spinal patients at a national scale. The government’s decision to hold a public inquiry — and the inquiry’s decision to uphold the findings — validated both the analytical methodology and the scale of the problem. Kirontech is now in active dialogue with the Australian Department of Health about embedding this capability into the country’s payment integrity infrastructure.