MAC + UPIC + state Medicaid

Hospice Fraud Detection

Hospice election validity, terminal-illness documentation, length-of-stay anomalies, GIP-day audits, and cross-provider recidivism.

The hospice fraud landscape

Understanding the complexities of hospice fraud

Hospice fraud is a significant concern for Medicare Administrative Contractors (MACs), Utilization and Payment Control (UPIC) programs, and state Medicaid agencies. It encompasses a range of illicit activities, including invalid hospice elections, insufficient terminal-illness documentation, length-of-stay anomalies, and General Inpatient (GIP) day audits. Cross-provider recidivism across the John Doe synthetic engagement pattern further complicates detection efforts.

The Total Addressable Market (TAM) for hospice fraud detection is a subset of the CMS $30 billion priority lanes, highlighting the critical need for robust solutions.

How JIL closes it

JIL Sovereign's approach to hospice fraud detection

JIL Sovereign addresses hospice fraud through a comprehensive set of 14 attestation checks that cover hospice election validity, terminal-illness documentation, length-of-stay anomalies, GIP-day audits, and cross-provider recidivism. These checks are integrated into the existing JIL Bi-Directional Payment Integrity Network, leveraging the four-pillar architecture (RAN, CourtChain, PoCS, Sealed Escrow) to deliver Court-Ready Evidence Bundles (CREB).

By utilizing authoritative cross-source datasets and a sophisticated packaging layer, JIL Sovereign ensures that the integrity signals are mapped into the buyer's language and rendered in their evidentiary format, providing a robust solution for detecting and combating hospice fraud.

John Doe case study (synthetic)

A synthetic case study: Detecting hospice fraud with JIL Sovereign

In a synthetic case study involving the John Doe engagement pattern, JIL Sovereign successfully identified multiple instances of hospice fraud. The platform's 14 attestation checks flagged invalid hospice elections, insufficient terminal-illness documentation, and length-of-stay anomalies. Additionally, the platform detected cross-provider recidivism, providing comprehensive evidence for further investigation and legal action.

This case study demonstrates JIL Sovereign's capability to deliver actionable insights and Court-Ready Evidence Bundles, enabling MACs, UPIC programs, and state Medicaid agencies to effectively combat hospice fraud.

Pricing

JIL Sovereign pricing structure

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(TM) 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

To demonstrate the effectiveness of JIL Sovereign in detecting hospice fraud, we offer a 90-day pilot program. During this period, MACs, UPIC programs, and state Medicaid agencies can access the platform's full suite of 14 attestation checks and generate Court-Ready Evidence Bundles.

The 90-day pilot allows buyers to evaluate the platform's capabilities, understand its impact on their operations, and make an informed decision about integrating JIL Sovereign into their hospice fraud detection efforts.