Detect early. Prove it. Stay safe.
JIL's retroactive detection plus AVE Tier 2 investigation gets MCOs and Medicaid payers inside the 60-Day Rule safe harbor. We identify fraudulent settlements, document the good-faith investigation, and produce Court Ready Evidence Models (CREBs) anchored on CourtChain. The customer acts on the evidence.
Three ways to evaluate AVE.
Whether you are sizing the exposure, vetting the workflow, or moving to scope, pick the surface that fits your role.
You paid the fraud. Under federal law, you may already owe it back.
The CMS 60-Day Rule (42 USC 1320a-7k(d), final rule effective January 1, 2025) applies directly to Medicaid managed care organizations, Medicare Advantage organizations, and prescription drug plan sponsors. When you identify an overpayment, you have 60 days to report and return it. Retention past 60 days creates reverse False Claims Act liability under 31 USC 3729(a)(1)(G).
Under Schutte v. SuperValu (598 U.S. ___ (2023)), the FCA "knowingly" standard includes actual knowledge, deliberate ignorance, and reckless disregard. You cannot escape FCA exposure by failing to look. The clock starts when fraud is identifiable, not when you choose to identify it.
The framework, in four pieces.
42 USC 1320a-7k(d). Identify, report, return within 60 days. Retention is reverse FCA liability.
31 USC 3729(a)(1)(G). Liability for knowingly retaining an identified overpayment. FCA penalty range $14,308 to $28,619 per claim, plus treble damages.
CMS Final Rule effective January 1, 2025 provides up to a 180-day suspension of the 60-day clock for a documented good-faith investigation. Investigations longer than 180 days risk losing the safe harbor on a "good faith" challenge.
DOJ explicitly recognizes self-disclosure, documented internal investigations, and remedial action as factors that reduce penalties or damage multiples. Source: DOJ Civil Division FY 2025 enforcement summary, $6.8B in recoveries, 1,297 qui tam filings.
Whistleblowers are the leading detection mechanism. FY 2025 saw 1,297 qui tam filings and $6.8B in DOJ FCA recoveries, of which $5.7B was healthcare. If you do not detect your fraud first, somebody else has every incentive to. When they do, you lose the cooperation credit and face the full statutory penalty.
"Validate these settlements" is not the customer's actual problem.
A Tier 1 retroactive scan against an MCO or hospital system settlement ledger surfaces a flagged set: settlements made to fraudulent institutions, settlements containing fraud markers, or settlements to providers later determined non-compliant. At enterprise scale, this set ranges from tens of thousands to over one million flagged settlements per engagement.
The customer's actual problem is two-fold:
- Get inside the safe harbor. Identify the fraud, document the investigation, build the cooperation-credit posture before a whistleblower files first.
- Get to the operator. For most real-world enterprise fraud, the unit of action is the bad actor, not the individual claim. The bad actor is hidden behind a stack of LLCs, holding companies, and nominee owners.
Minnesota autism daycare networks, California hospice mills, and NPI farming rings all share the operator-network shape: one or a small number of human operators controlling many shell entities, generating thousands of fraudulent settlements that are far more powerful as one consolidated proof case than as thousands of individual claim findings.
Three internal teams consume the evidence.
Pursues claim-level recovery through standard payer dispute processes.
Owns bad-actor casework and supports civil suits naming human operators.
Documents disposition for regulators, CMS reporting, and audit defense.
A fourth audience is structurally invisible until needed: DOJ, when reviewing the customer's cooperation posture. AVE produces evidence that serves all four.
Tier 1 detection. Tier 2 investigation. Pre-Settlement attestation.
Three components map directly to the FCA compliance framework. Tier 1 starts the safe-harbor clock. Tier 2 documents the investigation. Pre-Settlement prevents the exposure from arising.
Retroactive Detection
4 weeks. Scan four years of settled claims. Surface fraudulent settlements at claim level, entity level, and operator-network level. Hand you the report.
Strategic effect
You have now identified the overpayment for purposes of the 60-Day Rule. The safe-harbor clock starts. You are inside the 180-day investigation window.
Deliverable
Tier 1 detection report, Bad Actor candidate list, recommended Tier 2 escalations, safe-harbor documentation.
Per-Case Investigation
A la carte. For settlements you escalate, AVE produces the documented good-faith investigation. UBO resolution, bank account fingerprinting, premise classification, network detection.
Strategic effect
This is the documentation that supports cooperation credit. CREB anchored on CourtChain (FRE 902(14)) survives discovery in any forum.
Deliverable
Per-claim, per-entity, or per-network CREB. Supporting evidence package. Recommended action path.
Continuous Attestation
Annual contract. Continuous Tier 1 detection on incoming settlements before payment leaves treasury. Confirmed bad actors flow from the registry into the attestation.
Strategic effect
You never cross the "knowingly retained" threshold because flagged settlements never settle. The exposure does not arise.
Deliverable
Real-time attestation on incoming settlements. Same Tier 1 to Tier 2 escalation pattern when fraud is detected.
See AVE Tier 2 in action - walk through a real operator network
Step through entity resolution, UBO chain walk, bank account fingerprinting, premise classification, network graph overlay, and CREB assembly on a representative hospice ring. No paperwork. Authoritative source: retail.jilsovereign.com.
Open the AVE demoEight investigation categories. One unified entity graph.
AVE is an agentic AI engine. The decision logic is table-driven; policy lives in data, not code. Every artifact is locked to template version, model version, and input data hash for reproducibility under discovery.
Each capability has a runnable scenario on the live demo. Click "See it in the demo" on any card to jump to the corresponding scenario walkthrough on /ave-demo.
Claim-level patterns
14 fraud patterns: upcoded CPT, phantom NPI, duplicate billing, unbundling, deceased-patient billing, excluded provider, geographic impossibility, statistical outlier, beneficiary identity mismatch, unauthorized telehealth, network coordinated fraud, kickback pattern, medical necessity absent, services not rendered.
UBO Resolution
Walk the corporate ownership chain. FinCEN BOI (Corporate Transparency Act), state SOS filings, IRS EIN records, OpenCorporates, SEC filings, public records. Output: ownership chain per entity, resolved UBOs, confidence score, source citations defensible in court.
See it in the demo: Multi-state UBO ring (13 states, $227M) ->
Bank Account Fingerprinting
Salted hash at ingest, raw account numbers never persisted (GLBA-compliant by design). Fourteen entities with different paper ownership all depositing into three shared accounts with one common signatory is a fraud signal paper cannot hide.
Premise Classification
USPS classification, Google Places categorization, public property records, zoning data, virtual office and mailbox-service registries, AI Street View image analysis. The building cannot lie.
Business-Premise Compatibility
Hospice in retail strip mall, autism daycare at gas station, DME supplier at a UPS Store mailbox. Hard mismatches are the highest-value evidentiary signals. Defensible in court without expert testimony.
See it in the demo: Therapy practice on a daycare premise ->
Volume Capacity Analysis
Can the premise physically support the billed volume? 1,840 hospice patient-days in Q3 requires roughly 20 occupied beds. A 1,400 sqft unit cannot.
See it in the demo: Phantom telehealth, 18 hrs/day per provider ->
Exclusion List Cross-Reference
LEIE (OIG), SAM (federal), OFAC, state Medicaid exclusions. Excluded-provider hits anchor criminality signal.
Network Detection
Four overlaid graphs: corporate ownership (UBO), financial flow (bank fingerprint and signatory), address co-location, premise-mismatch overlay. Convergence is the high-confidence operator network. Divergence between corporate paper and financial reality is itself evidence of deliberate concealment.
See it in the demo: John Doe ring, all 5 anchors firing (live) ->
What detection costs vs what failure to detect costs.
Illustrative case for a multi-state MCO with 1,000 undetected fraudulent settlements over four years and $5M in underlying overpayments.
Without JIL
- 1,000 undetected fraudulent settlements over 4 years
- $5M underlying overpayments
- Whistleblower files qui tam
- FCA penalty: $14,308 to $28,619 per claim
- Treble damages: $15M
With JIL Tier 1
- Annual flat fee (scaled by MCO size, see Pricing section)
- Identifies the fraud, starts the safe-harbor clock
- Tier 2 a la carte only on cases you escalate
- Cooperation credit on self-disclosure
- Documented good-faith investigation within 180-day window
Detect early. Pay for proof. Stay safe. The customer who self-discloses with a documented investigation pays a fraction of the customer who gets caught. JIL is the documentation layer that makes self-disclosure defensible.
Three line items. No surprises.
Pricing reflects that JIL is a detection, proof, and attestation company. Fixed-fee for the detection layer, a la carte for per-case investigation. Customer always sees cost before authorizing work. Sealed Escrow caps every per-case engagement at the protocol level.
Retroactive Detection
$150K - $750K annual flat fee, scaled by MCO size.
- Regional MCO (single state, hundreds of thousands of covered lives): $150K-$300K
- Multi-state MCO: $300K-$500K
- National MCO or state Medicaid: $500K-$750K
Includes full four-year retroactive scan, 14-pattern fraud taxonomy, initial entity grouping, Bad Actor candidate identification, Tier 1 detection report, recommended Tier 2 escalations.
Per-Case Investigation
A la carte. Customer authorizes per case. Price shown before authorization.
Per-case pricing factors: investigation depth, number of entities or settlements under investigation, UBO resolution complexity, premise classification scope, CREB packaging granularity, configuration depth.
AVE optimizes the customer's cost exposure for remediation and civil adjudication. Investigation depth selected to deliver the evidence the customer needs at the lowest defensible cost.
Annual Contract
Up to $5M annual flat fee, scaled by settlement volume.
Real-time attestation on incoming settlements. Continuous Tier 1 detection before payment leaves treasury. Same Tier 1 to Tier 2 escalation pattern when fraud is detected.
First-year credit: if you sign a Pre-Settlement annual contract within 12 months of completing a Tier 1 retroactive scan, 50% of whatever you paid for the Tier 1 scan credits to year 1 of Pre-Settlement.
What a recommended action path actually looks like.
For every significant grouping, AVE produces four artifacts attached to the CREB. The example below is a representative output for a hospice ring detected during entity resolution. Investigator review and approval gates inclusion in the locked CREB.
Grouping: Network of 14 entities controlled by John Doe
Linkage agreement score 0.91. Nine premise mismatches. Three shared bank accounts. Conflicting UBO and bank evidence on parent LLC.
1. Grouping basis
UBO resolution returns John Doe as Ultimate Beneficial Owner across 12 of 14 entities (FinCEN BOI plus Delaware Secretary of State, confidence 0.92). Bank account fingerprinting links 12 of 14 entities to three shared receiving accounts with John Doe as signatory of record. Premise classification flags 9 of 14 registered service addresses as retail strip mall units; two as mailbox-service addresses; one as a vacant lot.
2. Anomalies found
Hospice in retail strip mall (high). Entity claims to operate as inpatient hospice but is registered at a 1,400 sqft commercial retail unit. USPS classifies as retail; Google Places shows no medical signage; Street View shows no medical-grade entrance. Inpatient hospice operations require licensed clinical space physically incompatible with this premise.
Volume impossible for premise (high). Entity billed 1,840 hospice patient-days in Q3, requiring approximately 20 occupied beds. Premise is 1,400 sqft.
UBO conflict (critical). SOS filings name Jane Smith. FinCEN BOI names Robert Jones. Bank signatory is John Doe. Three different humans, no disclosed affiliation. Pattern indicates deliberate ownership concealment.
3. Remediation guidance (advisory)
JIL does not execute remediation. The customer does. Guidance is structured for customer teams with FCA-aware timing.
For confirmed fraudulent groupings within active 60-day investigation window: plan to either return the overpayment within 60 days of identification, or document continuing good-faith investigation up to the 180-day cap.
For confirmed bad-actor networks: Pre-Settlement registry update should occur immediately; downstream civil action and OIG referral are customer-driven.
For findings that warrant self-disclosure: the evidence package and CREB are formatted to support voluntary disclosure to DOJ with cooperation-credit posture intact.
4. Recommended action path
evidence_supports: civil_action, oig_referral, internal_recovery, pre_settlement_block, compliance_documentation, fca_self_disclosure
AVE will produce: Network CREB anchored on CourtChain (FRE 902(14)). UBO resolution chain with FinCEN BOI citations. Bank fingerprint evidence package. Premise classification with Street View imagery.
Customer can pursue (using AVE evidence): Civil action against John Doe naming all 14 entities. OIG / DOJ self-disclosure with cooperation credit. State MFCU coordination. Pre-Settlement block (if contract active). Internal recovery team claim-level dispute process. Compliance attestation under the 60-Day Rule.
AVE produces evidence. The customer chooses what to do with it.
CREBs are designed to be reusable across forums. The customer can pursue any combination of the action postures below. Every one is supported by the same underlying evidence package.
Civil litigation
Customer's outside counsel uses network CREB, UBO chain, and bank fingerprint evidence to file civil action against the named human operator.
FCA self-disclosure
Customer's general counsel uses CREB, attestation records, and engagement file to make a voluntary self-disclosure to DOJ, capturing cooperation credit.
Internal recovery
Customer's Recovery / Payment Integrity team uses CREB and supporting documentation to pursue claim-level recovery through standard payer dispute processes.
OIG / DOJ referral
Customer's general counsel and chief compliance officer authorize OIG / DOJ referral, state MFCU coordination, and SAR filings.
Pre-Settlement block
Confirmed fraudulent UBOs, entities, premises, and bank fingerprints flow from the Bad Actor Registry into Pre-Settlement attestation. Future settlements blocked at the customer's payment system before clearing.
Compliance documentation
Customer's compliance team uses CREB and disposition records to satisfy 60-Day Rule obligations, audit defense, CMS reporting, and regulator inquiries.
Each engagement makes you stronger.
Every confirmed-fraudulent UBO, bank account, premise, and entity from an engagement flows into your Bad Actor Registry. The next engagement runs against a richer registry. New shells controlled by registered humans are flagged before the first payment clears. Bank accounts known to fraud are blocked regardless of which entity is named on the receiving account. Premise classifications persist forever.
What the rings can change
- LLC names and corporate registrations
- Bank accounts (with effort)
- Registered agents and nominees
What the rings cannot easily change
- The physical buildings they operate from
- The cross-validation between corporate paper, financial flow, and physical reality
- The confirmed UBO once a human is named in a court filing
The fraud rings change LLC names. They cannot change humans, bank accounts, or buildings. JIL is not a vendor. It is institutional infrastructure that compounds.
Detection. Proof. Attestation. The customer acts.
The fraud is already in your data. The 60-day clock is already running. Someone is already looking. Be first. Be documented. Be safe.
AVE engagements start with a structured intake conversation: target evidence depth, FCA posture, internal team capacity, external counsel arrangement, prior-case context, regulatory landscape, data authorizations. Tier 1 is a self-contained 4-6 week engagement. No commitment to Tier 2 or Pre-Settlement.
For Managed Care Organizations, state Medicaid agencies, Medicare Advantage organizations, prescription drug plan sponsors, and hospital system compliance teams. AVE runs inside the JIL Sovereign Stack as a HIPAA-compliant institutional zone service. PHI never crosses into retail or consumer infrastructure.
Source citations
- 60-Day Rule: 42 USC 1320a-7k(d), CMS Final Rule effective January 1, 2025.
- Reverse FCA liability: 31 USC 3729(a)(1)(G).
- FCA penalty range (July 2025): DOJ Civil Division, 90 Fed. Reg. 29445. $14,308 minimum to $28,619 maximum per claim, plus treble damages.
- Schutte v. SuperValu standard: 598 U.S. ___ (2023). Knowingly = actual knowledge, deliberate ignorance, or reckless disregard.
- FY 2025 DOJ recoveries: DOJ Office of Public Affairs press release, January 2026. $6.8B in FCA recoveries, $5.7B healthcare, 1,297 qui tam filings.
- Cooperation credits: DOJ Civil Division FY 2025 enforcement summary.