This is not a vendor consolidation pitch. Your existing PI vendors (Cotiviti, HMS, EXL, internal) catch the leakage they were built to catch — claim edits, DRG validation, TPL. JIL catches what no rules engine and no contingency-RAC can: the systemic patterns CMS PERM keeps citing. Multi-year recidivism across 3+ program years. LEIE-excluded providers still billing 8 years post-exclusion. CMRA / mailbox-address suppliers. Deceased-beneficiary billing. That's the 91% of the loss pool CMS measures but nobody recovers — because it requires cross-system joins nobody runs nightly. JIL runs them. Every claim. Every night. The wins belong to your SIU.
JIL is the back-office. Your SIU is the front line. Every case JIL surfaces enters your queue with substantiation already in hand. Your team approves, escalates, and takes credit. JIL never appears on the docket or in the OIG referral packet — only your SIU does.
Your headcount stays. Your vendor stack stays. Your relationships stay.
42 CFR 422.503 (MA compliance program), 42 CFR 438.608 (Medicaid MCO FWA), ERISA §404 (fiduciary duty), SOX §404 (internal controls). One CourtChain™ anchor + FRE 902(13)/(14) CREB™ documents discharge of all four — measurably, in court-admissible form, against a public CMS dataset.
When the OIG, state AG, or a qui-tam relator comes calling: you have receipts.
Flat fee = 10–15% of your CMS-disclosed program-integrity contractor spend, capped, predictable. Contingency = 10% of net cash recovered, performance-aligned. Industry-standard SIU contingency is 15–25% of recovery. Outside counsel runs 33%.
Both pricing legs are publicly anchored. Both auditable line items.
| Line | Y1 | Y2 | Y3 | 3-yr cum. |
|---|---|---|---|---|
| Retro recovery realized (Y1 33% / Y2 40% / Y3 27% of $12.3B pool) | $4.04B | $4.92B | $3.31B | $12.27B |
| Forward recovery realized (50% / 75% / 100% of $5.25B/yr) | $2.63B | $3.94B | $5.25B | $11.82B |
| Total MCO recovery realized | $6.67B | $8.86B | $8.56B | $24.09B |
| JIL retro-active scan (one-time, Y1 baseline build) | $3.2M | — | — | $3.2M |
| JIL flat fee (12.5% × $1.4B disclosed PI spend, capped) | $175M | $175M | $175M | $525M |
| JIL contingency (10% × net cash recovered) | $667M | $886M | $856M | $2,409M |
| Total JIL revenue | $845M | $1,061M | $1,031M | $2,937M |
| MCO net benefit | $5.83B | $7.80B | $7.53B | $21.16B |
| 3-yr cumulative | Conservative (15%) | Target (25%) | Aggressive (40%) |
|---|---|---|---|
| MCO recovery realized | $14.44B | $24.09B | $38.50B |
| JIL retro scan + 3-yr flat fees | $528M | $528M | $528M |
| JIL contingency (10% × recovery) | $1,444M | $2,409M | $3,850M |
| Total JIL revenue 3-yr | $1.97B | $2.94B | $4.38B |
| MCO net benefit 3-yr | $12.47B | $21.16B | $34.12B |
| 3-yr ROI on JIL spend | 6.3× | 7.2× | 7.8× |
Capture rates anchored to JIL's 11-engagement portfolio on real CMS Snowflake data ($29.5B surfaced at risk, $9.53B recovery high = ~32% capture against surfaced pool — between Target and Aggressive). Realization curves (Y1 33% / Y2 40% / Y3 27% retro; 50% / 75% / 100% forward) reflect typical MAC appeal + DOJ FCA + state MFCU recovery timelines. Aggressive band assumes JIL Corridor cross-MCO joins are wired by Y2.
Cotiviti, HMS, EXL, internal SIU, outside counsel — all continue under their current scope. JIL operates parallel, surfacing the long-tail your current stack architecturally cannot catch. Zero displacement.
SIU receives pre-substantiated CREB™ packets. SIU approves the OIG SDP / DOJ FCA / state MFCU referral. JIL is acknowledged on the technical exhibit only — never as relator, never as fact witness, never on the docket cover.
Every finding anchored to CourtChain™ + FRE 902(13)/(14) self-authenticating. When CMS, state AG, or a qui-tam relator asks "did you have a reasonable detection program?" the answer is verifiable, court-ready, dated, signed.
| Capability | Cotiviti / HMS / Optum-internal | JIL Sovereign |
|---|---|---|
| Cadence | Quarterly / monthly audits, sampling-based | Nightly Tier-1 + biweekly closed-loop auto-submit to legal |
| Triage | Flagged-claim list → SIU human review (weeks per case) | AVA clusters + T2 auto-substantiation + CREB™ (hours per case) |
| Evidence | Flagged-claim spreadsheet with reason codes | FRE 902(13)/(14) self-authenticating CREB™ on CourtChain™ |
| Legal hand-off | SIU writes the referral; legal rebuilds for filing | Auto-submit to your legal team's queue, packets pre-formatted for OIG SDP / DOJ FCA / state MFCU |
| Scope | Healthcare claim editing + DRG + COB; post-payment only | Pre-settlement + retro · MCO + SNAP + Transportation + VA + Bank + Capital Markets on one contract |
| Data residency | Data shipped to vendor; vendor holds at rest | Runs in your Snowflake / Databricks. JIL holds zero data at rest. SOC 2 inherits from your stack. |
| Pricing | 15–25% contingency plus subscription / per-finding | 10% net-recovery contingency + flat fee capped at 10–15% of your CMS-disclosed PI budget |
| Pattern (CMS PERM-cited) | Why architectural — not a vendor failing | JIL closes it via |
|---|---|---|
| Multi-year recidivism (3+ years) | Each program year is a separate engagement; nobody stitches across | AVA max-lookback rule; FCA scienter built in |
| LEIE post-exclusion billing | No vendor runs 83K LEIE × 259M Part-D rows nightly | Snowflake compute · nightly LEIE×CMS cross-walk |
| CMRA / phantom-premise suppliers | Field investigation cost prohibitive at scale | USPS-CMRA registry + Lob.com CASS+DPV (live) |
| Deceased-beneficiary billing | Single-case prosecution under-recovers; needs cohort scale | CMS deceased file × utilization cross-walk per program-year |
| PECOS-deactivated providers still billing | Cross-system reconciliation — not in any SIU's job description | PECOS × NPPES diff overlay on every claim |
| DRG creep / upcoding drift over time | Year-over-year comparison requires multi-vintage joins | AVA agentic clustering across multi-year DRG distributions |
Onboarding: $1M flat, all-in, no per-finding charges during the pilot. JIL embeds 2 forensic analysts under your SIU's direction. Snowflake feed live in 5 business days. AVA workspace + CREB™ generation live in 10 days.
Pilot deliverables (your SIU's name on every one):
Asymmetric downside: If the 90-day deliverables miss, the $1M converts to a 6-month platform credit + contingency drops from 10% to 7.5%. No other vendor in MCO PI takes pure downside on the math.