MAC + UPIC + state Medicaid

Behavioral Health Fraud Detection

Behavioral health and substance-use disorder claim integrity: telehealth licensure, group-therapy attendance, member-level coverage validation, dosage anomalies.

Executive Summary Architecture Use Cases Demo / POC Technical DesignGated

The BH/SUD fraud landscape

Understanding the Scope of Behavioral Health Fraud

Behavioral health and substance-use disorder (BH/SUD) fraud is a growing concern for Medicare and Medicaid programs. This section outlines the key areas of fraud within BH/SUD claims, including telehealth licensure, group-therapy attendance, member-level coverage validation, and dosage anomalies.

Fraud in this sector not only diverts funds but also compromises patient care and safety. The total addressable market (TAM) for BH/SUD fraud detection is a subset of the broader Medicare/Medicaid payment integrity market, highlighting the need for specialized solutions.

How JIL closes it

JIL Sovereign's Approach to Behavioral Health Fraud Detection

JIL Sovereign addresses BH/SUD fraud through a roadmap of attestation checks (in development) designed to validate claim integrity. These checks target critical areas such as telehealth licensure verification, group-therapy attendance confirmation, member-level coverage validation, and dosage anomaly detection.

By leveraging public data and commercial datasets, JIL Sovereign ensures that every claim is scrutinized against multiple integrity signals, providing buyers with court-ready evidence bundles (CREB) that are anchored under FRE 902(14).

Pricing

Transparent and Scalable Pricing Model

JIL Sovereign offers a transparent and scalable pricing model to fit the needs of various buyers, including MACs, UPICs, and state Medicaid programs. Our pricing is designed to provide maximum value while ensuring affordability.

Pricing -- Fraud Pillar Standard

One model. Bottom-line aligned.

Retroactive scan
one-time, scoped to volume
4-year minimum lookback. Builds the base dataset. Proves the closed-loop economics before the flat-fee leg starts.
Flat fee
12.5% of disclosed PI spend
Annual, capped. Covers nightly T1 + AVA + T2 + CREB® generation. Below the industry-standard 15 to 25% SIU contingency.
Contingency
10% of net cash recovered
Performance-aligned. Fires only on actual recovered cash, net of MAC appeal, settlement, and pursuit. Outside counsel runs 33%.
90-day pilot
$1M all-in, asymmetric downside
If Day 90 deliverables miss, the $1M converts to a 6-month platform credit and contingency drops from 10% to 7.5%. No other vendor in PI takes pure downside on the math.

Pricing anchored to public 10-K Schedule H disclosures + CMS PERM 2024. UHG-scale case study available at /products/mco-flat-fee.

90-day pilot

Experience JIL Sovereign with a 90-Day Pilot

We invite you to experience the effectiveness of JIL Sovereign's BH/SUD fraud detection capabilities with a 90-day pilot program. This pilot will allow you to test our solution in a real-world setting, providing you with tangible evidence of its impact on your payment integrity efforts.

During the pilot, you will work with the attestation checks available as the BH/SUD engine is built out, enabling you to detect and mitigate fraud more effectively as coverage expands. We are confident that you will see meaningful improvements in your fraud detection and overall payment integrity.