Product / Medicare Claim Attestationjilsovereign.com/docs/medicare
On This Page
01 DRG Upcoding Detection 02 Provider Credentialing Integrity 03 Duplicate and Phantom Billing 04 Part D Prescription Attestation 05 How It Works 06 Public Data Integration 07 What You Get 08 What This Is Not 09 Pricing and Engagement 10 Demo and POC
Healthcare Fraud Detection

Medicare Claim Attestation

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.

Medicare fraud costs the federal government an estimated $60 billion annually. Most detection happens after the claim has paid. JIL Medicare Claim Attestation applies the full Verdict Engine to every Medicare claim, whether in-flight or historical, validating against public data sources, provider credentialing records, DRG coding patterns, and known fraud typologies. Every finding is sealed to CourtChain™. Not an alert. Evidence.
28
Federal data feeds
175
Attestation checks
$1.18B
DRG cohort overage (POC)
FRE 902
Self-authenticating
01DRG Upcoding Detection

The Verdict Engine validates DRG assignment against clinical documentation, procedure codes, and diagnosis hierarchies. Systematic upcoding patterns are identified across providers, facilities, and geographic cohorts. JIL's public-data POC identified $1.18B in DRG cohort overage using only publicly available CMS data. Every finding is sealed with structured evidence for OIG referral or internal action.

02Provider Credentialing Integrity

Every claim is validated against the provider's current credentialing status, licensure, specialty scope, and exclusion status. The Verdict Engine cross-references NPPES, OIG LEIE, SAM.gov, and state licensing boards in real time. Claims submitted by excluded, expired, or out-of-scope providers are flagged before settlement with sealed evidence of the credentialing defect.

03Duplicate and Phantom Billing

Cross-claim analysis identifies duplicate submissions across TINs, NPIs, and billing entities. Phantom billing patterns (services not rendered, patients not seen, facilities not staffed) are detected through geographic, temporal, and volume anomaly analysis. Flagged patterns are registered in the Bad Actor Registry and sealed with structured evidence for law enforcement referral.

04Part D Prescription Attestation

Part D claims are validated against formulary compliance, prescriber authority, patient eligibility, and known diversion patterns. The Verdict Engine flags claims where the prescriber lacks the appropriate DEA registration, the quantity exceeds clinical norms, or the patient's medication history suggests diversion or doctor-shopping. Each finding is sealed with full evidence lineage.

05How it works
28 public CMS feeds · PHI never required · qui tam referral pack
Medicare Claim Attestation - Public-Data Verdict + OIG / DOJ Referral Medicare claims (Part A, B, C, D) enter via API or batch. The Verdict Engine cross-references 28 public federal feeds (CMS, NPPES, OIG LEIE, SAM.gov, FDA NDC, CDC, state boards). Most of the pipeline never touches PHI; PHI enters only on explicit case escalation through a Tier-2 enclave. Output: pass claim, flag for review, or block + referral pack for OIG, DOJ, or qui tam channels. Medicare claim input Verdict Engine · Tier 1 (public data) + Tier 2 (PHI enclave) Outcomes + referral Part A claims inpatient + skilled nursing Part B claims physician + outpatient Part C (MA plan) MAO encounter records Part D Rx PDP / formulary / DEA 28 federal feeds CMS / NPPES / OIG LEIE SAM / FDA NDC / state boards Medicare Verdict Engine 175 checks · 18 capmarkets vertical-specific · 148 universal TIER 1 - PUBLIC DATA - PHI-FREE DRG upcoding LEIE excluded SAM debarment NPPES Duplicate TIN Phantom bill DEA / Sched II Geo anom TIER 2 · PHI ENCLAVE · ONLY ON ESCALATION PHI enters under DUA + BAA · separate keys · air-gapped enclave Clinical reasoning Medical necessity Case review Pass Claim settles No findings flagged Review / MCO queue CREB™ routed to SIU Pre-settlement hold OIG / DOJ referral Qui tam pack ready FRE 902(14) sealed POC reference $1.18B DRG cohort overage · public data only CourtChain™ seal · Medicare / Medicaid · qui tam-ready · PHI handled at Tier 2+ only

Medicare Claim Attestation operates in two modes. Pre-settlement mode integrates with the MCO's or MAC's claims adjudication workflow via API or Connector SDK, attesting each claim before payment. Retroactive mode ingests historical claims data in batch and runs the full Verdict Engine against every settled claim. Both modes produce the same CREB™ packaging, the same CourtChain™ seal, and the same evidentiary standard. Integration takes 8 to 12 weeks to production.

06Public data integration
  • 28 federal data feeds. CMS, NPPES, OIG LEIE, SAM.gov, FDA NDC, CDC, state licensing boards, and more. Continuously updated.
  • Public-Data POC available. JIL can demonstrate detection capability using only publicly available CMS data. No PHI required for initial proof of value.
  • PHI handled at Tier 2/3 only. Most of JIL's pipeline never touches PHI. PHI enters only on explicit case escalation, in an isolated enclave with a separate access boundary.
  • CMS Data Source Map. Full mapping of 28 federal data feeds published at jilsovereign.com/cms-data-source-map.
07What you get
  • Full Verdict Engine. All 175 checks applied to Medicare and Medicaid claims. DRG, credentialing, duplication, Part D, and more.
  • Sealed evidence per finding. CREB™ issued for every flagged claim. FRE 902(14) self-authenticating. Ready for OIG, DOJ, or qui tam referral.
  • Bad Actor Registry. Systematic patterns registered and cross-referenced across the network.
  • Recovery Infrastructure mapping. Findings mapped to counsel, funders, and enforcement channels for downstream recovery action.
08What this is not
09Pricing and engagement
MCO / MACFlat-fee subscription for pre-settlement attestation. Volume tiers based on claims throughput. No contingency.
GovernmentAgency-level licensing for CMS, OIG, or state Medicaid. Scoped to program-specific detection requirements.
RetroactiveFlat-fee per scan engagement. 12, 24, or 36 month lookback. Typical delivery: 2 to 4 weeks per 12-month book.
Public-Data POCProof-of-value engagement using only publicly available CMS data. No PHI. No BAA required. Demonstrates detection capability before full integration.

See $1.18B in DRG overage identified from public data alone.

Request the Public-Data POC walkthrough or begin a scoped pilot on a defined claims population. No NDA required for the first session. No PHI required for proof of value.

POCjilsovereign.com/ava-pocDemojilsovereign.com/demoData Sourcesjilsovereign.com/cms-data-source-map