Purpose-built attestation for Medicare and Medicaid claims. DRG upcoding, phantom billing, credential fraud, and Part D prescription abuse detected before settlement or identified in historical claims, with court-ready evidence on every finding. Powered by 28 federal public data feeds and the full Verdict Engine.
| Audience | MCOs, state Medicaid integrity programs, RAC contractors, qui-tam firms post-CREB™. |
| Buyer | GC, CCO, VP Payment Integrity, RAC team lead. |
| Economic Model | Per-claim flat fee for pre-settlement; per-batch retro pricing; RADV defense subscription tier. |
| Partners | Plaid (banking fingerprint), CMS PECOS direct connection, OIG/State exclusion feeds. |
EDI 837/835, FHIR R4, custom CSV ingestion.
NCD/LCD/MUE/NCCI/Pub 100/PECOS/NPPES/LEIE/SAM/Open Payments/Provider Enrollment/etc.
Medicare-relevant subset of 175 checks - DRG, phantom-billing, credential, Part D, dual-eligible.
Cohort-baseline pattern engine - DRG-shift, length-of-stay outliers, billing-volume anomalies vs peers.
Each finding sealed with source citation + cohort baseline + finding pattern.
MCO ships Q4 inpatient batch (3,200 cases, $850K). Engine fires: 47 DRG-shift findings (DRG 470 to 469 in cohorts where the case-mix index doesn't support it; PEPPER baseline shows the hospital is in the 99th percentile for this shift). 12 false-positives. 35 confirmed upcoding pattern. Estimated overpayment: $164K. CREB™ sealed for each. MCO holds payment, refers to RAC. Within 27 days (FCA 60-Day Rule window), MCO has filed self-disclosure with CMS, avoiding qui-tam exposure.
| Detection | DRG-shift, phantom-billing, credential-fraud, Part D abuse, dual-eligible misclass |
| Cohort baseline | PEPPER + Medicare population - finding contextualized to peer hospital cohort |
| Modes | Pre-settlement (live) + retroactive (batch) |
| Defense | RADV + FCA 60-Day Rule timeline, sealed bundle ready |
| Throughput | <2s P95 pre-settlement; <12 min/M claims retroactive |