The Claims Ring

Director of Special Investigations, regional health insurer

The insurer bleeds tens of millions a year to fraudulent claims. A cluster of nominally 'competing' physical-therapy clinics keeps billing the same members in improbable sequences — the same patient treated at three rival clinics on overlapping dates — and their prescriptions all clear through one pharmacy. Anomaly scoring lights up before anyone knows where to look. The question: how big is the ring around this clinic, and can it be handed to a prosecutor? Every step touches patient records, so every step must be governed.