Thought leadership · on the record
When CMS asked the industry how program integrity should work, most vendors sent brochures. We sent doctrine. These are the six positions we put on the federal record — docket CMS-6098-NC — and run our company by.
letter no. 01 · the thesis
One-sided analysis isn't integrity; it's collection. The moment a payment-integrity system surfaces underpayments with the same rigor as overpayments, it stops being a vendor tool and starts being infrastructure both sides can stand on.
from our response to CMS-6098-NC · 2025
letter no. 02 · the standard
A black-box risk score should never be the basis for a payment determination. Per-claim, explainable factor analysis — cited to the contract, the code, the regulation in force on the date of service, and the chart — is the minimum standard for deciding what care is worth.
from our response to CMS-6098-NC · 2025
letter no. 03 · the doctrine
AI assembles and cites the evidence; a person makes every determination. When the evidence is in equipoise, the benefit of the doubt goes to the patient — and the claim routes to a human, not a rejection queue. The click always belongs to a person.
from our response to CMS-6098-NC · 2025
letter no. 04 · the inversion
Pay-and-chase is the apology; prevention is the product. Pre-payment models trained on post-payment outcomes end the recoupment cycle at its source — and every dollar that doesn't burn in the fight returns to care.
from our response to CMS-6098-NC · 2025
letter no. 05 · the manner
Most improper billing is confusion, not crime. A graduated response — educate, recoup, refer — distinguishes the willful from the lost, protects access in the places denial can close a hospital, and reserves enforcement for those who earned it.
from our response to CMS-6098-NC · 2025
letter no. 06 · the hunting ground
Inpatient runs ~2% improper and is policed relentlessly. Behavioral health runs 58%, physical therapy 61% — millions of small claims where rules engines can't tell a justified course of care from a non-tapering episode. Clinical signal and billing signal must be read together.
CMS CERT FY2024 · OIG audit series · our analysis
the full response runs sixty pages — citations included, naturally
