Case 3 · Provider Level · Asia-Pacific WHERE WE STARTED A blue-chip dermatology clinic in the Asia-Pacific region was billing for Mohs micrographic surgery at a rate that looked unremarkable in any single claim. Mohs is a highly specialised, high-cost procedure used to remove skin cancer in precise tissue layers — and at this clinic, it was presented as the…
Case 7 · Employer Level · United Kingdom WHERE WE STARTED A large UK employer — a household name — provides private medical insurance to employees through a self-funded arrangement administered by a major insurer and brokered by a leading employee benefits consultancy. Healthcare costs had been rising year on year. The question the employer and their broker wanted answered…
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…
Case 5 · Collusion Level · UK + International WHERE WE STARTED A large UK dental insurer was processing claims that, individually, fell within normal parameters. Viewed together, they formed the signature of an Organised Crime Group — identical invoices submitted under different patient names, from different regions, by people who shared financial and network connections invisible to any single-claim…
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…
Case 2 · Patient Level · United Kingdom WHERE WE STARTED A UK private health insurer was processing claims for a patient who had undergone complex multi-organ pelvic surgery for endometriosis. Within days, the patient was back in hospital — sigmoidoscopy, laparoscopy, upper GI endoscopy, repeat ureteric stenting — with three different surgeons involved over several weeks. Each claim passed…
Case 1 · Claim Level · Latin America WHERE WE STARTED One of Latin America’s largest national health insurers was processing high-value cardiac ablation claims from a hospital that had no cardiac ablation facilities. The claims passed standard validation — the procedure codes were legitimate, the amounts plausible. Nothing in the existing rules engine raised a flag. The fraud had…