Clinical Spend Analytics
Using an advanced AI and Machine Learning analytics platform and clinical expertise, we help detect activity not aligned with clinical need and improve recording accuracy to support system assurance and efficiency.
Supporting NHS teams to optimise processes and pathways
Enabling collaborative programmes with clear governance
Promoting resource stewardship and measurable service improvements
Current State
Based on our understanding, unwarranted variation and recording inconsistencies are reducing service efficiency and straining NHS resources.
System drivers: resource misallocation, duplicated pathways and recording inconsistencies
Scale (indicative): c. 6% of related expenditure may reflect incorrect activity (range 3%–8%)1
Independent sector: a material share of elective activity is delivered outside NHS oversight3
Immediate impact: inconsistent recording and variable oversight hinder effective resource reallocation, limiting opportunities to enhance service efficiency
£6.9bn
Based on core public spending* in 23/24 at £115.1bn2, 6% of potential incorrect activity equates to £6.9bn in funds that could otherwise be allocated to improve productivity
*Acute, Specialised services, Core mental health, Primary medical care
What the public sees in the UK
Examples of reported challenges
Incorrect activity and inaccurate recording:
Payment for services not provided or inaccurately recorded
Inefficient use of resources and unnecessary care:
Misuse of resources and delivery of unnecessary procedures or services
Billing and clinical recording inconsistencies:
Mistakes in billing or clinical documentation that affect accuracy and patient safety
Financial rigour supporting better healthcare through collaboration and assurance
Advanced analytics to identify incorrect activity and recording inconsistencies
Use AI-driven tools to spot anomalies in billing, coding, and utilisation across NHS and independent sectors Identify duplication, unnecessary procedures, and suspicious charging early to support accurate payments
Collaborative contract assurance
Provide near real-time monitoring of independent sector billing against agreed contracts to understand and manage the £2bn+ annual spend3 Help identify where billing volumes or procedure mixes deviate from expected patterns
Clinical & Financial Data Integration
Bring together disparate datasets (acute, specialised, mental health, primary care) into a unified view Translate clinical coding into actionable insights for commissioning and payment optimisation
Benchmarking & Risk Stratification
Benchmark hospital or clinic providers against national and local norms to highlight variation in cost, procedure rates, or coding Prioritise collaborative reviews where financial and patient impact is greatest
Proactive risk reduction and financial stewardship
Embed rules and machine learning models into payment processes to support prevention Work with NHS bodies to foster a culture of stewardship, safeguarding resources for reinvestment
Identification highlights
Procedure coding inconsistencies
Variations or errors in billing codes for routine procedures that can increase costs and reduce system trust
Unperformed Activity
Recording procedures not performed, causing financial discrepancies and diverting NHS resources
Unnecessary procedures
Interventions that may not be clinically needed, increasing costs and patient risk
Case selection variation
Some hospital or clinic providers focus on simpler cases, affecting resource use and care quality for complex patients
Benefits for the NHS
Optimise Healthcare Spend
By addressing incorrect activity and inefficiencies, more resources can be directed to essential care
Reduce Avoidable Expenditures
Targeting unwarranted variation frees funds for critical services and improves care quality
Strengthen public confidence
Transparent, collaborative assurance fosters trust in the healthcare system
Improve Patient Outcomes
Ensuring appropriate care leads to better experiences and healthier populations
Case study: Australia – Insights from Spinal Surgery billing analysis
Case study: Australia
Insights from Spinal Surgery billing analysis
An analysis of private health insurance billing for over 23,000 spinal surgery patients in Australia (Nov 2017–May 2023) revealed significant discrepancies in billing practices, including over-complex and extended service claims, and procedures performed without appropriate clinical diagnosis.
77%
of cases involved billing for more complex services than delivered
7%
involved spinal fusions without a documented diagnosis, breaching Medicare rules
10%
involved billing for longer service durations than provided
The de-identified data was supplied by six private health funds, representing 25% of the private health insurance market in Australia. Full story from ABC News Australia: https://www.youtube.com/watch?v=UyaKyS2wTQk Full report: ABC-Synapse-Kirotech-FinalReport-260324.pdf
Resulting actions
A government-led public enquiry confirmed these findings Several medical devices were banned or restricted due to safety concerns Legal prosecutions have been initiated, with ongoing investigations into other practices
NHS example: Cataracts
The risk to the NHS is well illustrated by the private cataracts contract.
Our partner’s independent experts were invited to comment on data presented by BBC Newsnight in March 2024. The data showed that private providers are increasingly claiming additional complexity and comorbidities in their coding.
According to the Royal College of Ophthalmologists, this trend cannot be explained by changes in the patient population. In fact, many patients were referred directly from opticians and likely have lower clinical complexity than those treated in hospitals.
This was highlighted this as a red flag, suggesting that complexity may be exaggerated, a phenomenon commonly referred to as ‘upcoding’ in private sector claims.
We are not aware of a significant payment integrity programme within the NHS. In contrast, private insurance companies typically operate active programs to detect and audit potential misbilling.
The estimated additional cost associated with upcoding in cataracts is approximately £29 million over a 24-month period5.
Future State
We envision a healthcare system built on fair and transparent partnerships, where incorrect activity and inefficiencies are significantly reduced.
The NHS moves toward a future where every pound of clinical spend, whether within the system or through independent providers, is tracked and assured in real time.
By addressing these vulnerabilities, funds that previously leaked are now safeguarded, enabling reinvestment into frontline care, reducing waiting lists, and strengthening public trust.
This ensures patients receive the highest quality care from every pound spent.
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