Evidence you can defend when the number gets audited

Providers and payers are both getting squeezed for cash. Cost is outpacing revenue on the provider side, and the rules that decide what gets paid are moving faster than anyone can track. Everybody needs a better reimbursement strategy, and almost nobody has trustworthy data underneath the one they already have.

The reason is structural, not organizational. CMS rebuilds its coverage database in place with no changelog. Payers republish their rate files monthly and nothing requires the prior version to stay available. So the number a strategy was built on frequently cannot be retrieved by the time it has to be defended. Between two of our own dated extracts, 22 coverage policies were revised.

Deep research into the source record itself: the CMS coverage record, national and local coverage determinations, coverage articles and the published comment history; state Medicaid policy across 28 states; commercial payer published rate files; Medicare physician and lab fee schedules; NCCI procedure-to-procedure edits; and hospital price transparency filings.

We preserve every source with its vintage, so an answer holds up a year later when someone asks which version applied on the date of service.

Coverage Intelligence

The living map of where a healthcare product gets paid, kept current. Read more →

GAVEL

The payer rulebook as software: will it be covered, what will it take, what will they pay, what did they just do. Read more →

Agent workforce

Agents that check enrollment, find notices and follow up on payment through the portals your staff already use. Read the case study →

Studio engagements

Claims edits, prior authorization, clinical policy review: the workflow owned end to end. Read more →

World models

Agents tested against the rules, with published refusal classes. Read more →

Genesee

The benchmark for payment-integrity agents: a synthetic hospital book with every leaked dollar labeled, no PHI. Read more →

Careers spent building AI and data systems inside these institutions, not a team that learned the domain in order to sell into it.

Take an orthopaedic and spine business. What does each payer actually publish for 27447, 27130, 22633 or 22551, in which market, on which date, and can you still prove it next year? We answer that, and we refuse to answer past our evidence.

• No unsupported denial rates. If the record does not carry it, no figure is served.
• No payment probabilities. What a payer published is not what it will pay on a claim.
• No claim that a payer covers a code. Coverage is reported with its citation and its date.

That is what makes it usable where the number gets audited. The refusal classes are published by our lab ↗.