01 · Executive Summary
The claim was processed. It was about to be paid.
Nobody verified it.
Self-funded employers pay billions annually in claims that were processed but never independently verified. The TPA adjudicates, the TPA pays, and the TPA audits its own work. Caliber inserts a seven-check verification layer between adjudication and payment on high-cost claims above $25,000. Advisory-only. We never deny claims, never contact providers, never touch member communications. We verify the bill, issue a Billing Governance Certificate, and route findings to the employer. The employer decides.
This is the simplest pilot in the portfolio. No technology integration. No member-facing component. No network disruption. A claims feed, a hold window, and credentialed reviewers. Caliber can be operational within 30 days of agreement and producing verified findings within the first week of claim intake.
4–6%
Expected discrepancy rate on high-cost claims above $25K
OIG / AHLA / MGMA benchmarks
$9.2M
Returned to payers by ClearBill (Joe's prior company) in its first six months of full deployment
ClearBill internal records
10 days
Standard turnaround from claim receipt to Billing Governance Certificate
BGS v1.0 specification
Caliber is not a retrospective audit. It does not look backward at claims already paid. It verifies claims in real time, during the TPA's existing hold window, before a dollar leaves the plan.
02 · Scope
What gets verified. What doesn't.
Caliber reviews claims above a $25,000 billed-amount threshold. This captures the claims that move the needle: high-cost facility stays, surgical episodes, complex imaging series, specialty pharmacy, and multi-day professional services. Claims below the threshold pass through untouched. The employer is not paying for someone to verify a $200 office visit.
Claim Types in Scope
| Claim Type | Form | Typical Triggers | Est. Monthly Vol. |
|---|
| Facility inpatient | 837-I (UB-04) | Surgical episodes, ICU stays, behavioral health residential, maternity with complications | Varies by pop. |
| Facility outpatient | 837-I (UB-04) | Ambulatory surgery centers, complex imaging, infusion series | Varies by pop. |
| Professional | 837-P (CMS-1500) | Multi-day surgical assist, anesthesia, high-cost specialty consults | Varies by pop. |
| Pharmacy (if applicable) | CSV / NCPDP | Specialty pharmacy claims above threshold (biologics, gene therapy) | Varies by pop. |
Estimated Monthly Volume by Population Size
| Covered Lives | Est. Claims >$25K / Month | Est. Annual Reviews | Reviewers Needed |
|---|
| 5,000 | 15–25 | 180–300 | 1 |
| 10,000 | 30–50 | 360–600 | 1 |
| 25,000 | 75–125 | 900–1,500 | 2–3 |
| 50,000 | 150–250 | 1,800–3,000 | 3–5 |
| 100,000+ | 300–500 | 3,600–6,000 | 6–10 |
Volume estimates based on typical self-funded employer claim distributions. Actual volume calibrated against employer's historical claims data during onboarding. Source: Milliman Health Cost Guidelines 2024; HCCI Healthy Marketplace Index.
Threshold Tiers
>$25K — Full Verification
All seven BGS checks applied. Billing Governance Certificate issued. Findings routed to employer within 10 business days.
$10K–$25K — Coding Verification
CODEVAL and BUNDLEVAL checks only. Flags unbundling and coding errors. Does not include rate or credential verification. Optional tier.
<$10K — Pass-Through
No review. Claims below $10K process through the TPA's standard workflow without Caliber involvement. At scale, automated CCI edit screening can be applied.
03 · Prerequisites from Employer
What we need before day one.
Caliber requires four things from the employer. Nothing else. No IT integration. No member communication. No network negotiation. The prerequisites are administrative, not technical.
01 · Claims Feed
High-cost claims extract from TPA
Weekly or daily extract of claims in hold status above the $25K threshold. Must include: claim ID, billed amount, diagnosis codes (ICD-10-CM), procedure codes (CPT/HCPCS), provider NPI, service dates, and plan terms. Accepted formats: 837-I/837-P (ANSI X12), CSV extract, or TPA-specific flat file.
Format specification provided during onboarding. Most TPAs can generate this extract from existing reporting modules within 1–2 business days.
02 · Hold Window
TPA agrees to hold claims for review
The TPA must hold claims above threshold for 10–14 business days before releasing payment. Most TPAs already operate with a 14–60 day hold window on high-cost claims for internal review. Caliber operates within this existing window. No extension of payment timing required in most cases.
If the TPA's standard hold window is shorter than 10 days, a 5-day expedited review protocol is available. See Section 05 (Workflow).
03 · BAA Execution
Business Associate Agreement
Standard HIPAA BAA covering claims data transmission and review. Caliber operates as a business associate of the employer, not the TPA. PHI handling, encryption standards, retention policies, and breach notification procedures are specified in the BAA.
Template BAA provided. Based on HHS model BAA provisions (45 CFR § 164.504(e)). Execution timeline: 5–10 business days with most employers.
04 · TPA Cooperation Letter
Written authorization to TPA
Employer issues a letter directing the TPA to (a) transmit weekly claims extracts above threshold and (b) hold flagged claims for the review window. This is the employer's fiduciary authority in action. The employer is not asking the TPA's permission — the employer is directing its own vendor.
Template cooperation letter provided. Most TPAs comply within one billing cycle. Some TPAs (Meritain, Aetna, Cigna) have existing data-sharing protocols that simplify this step.
What If the TPA Refuses?
It happens. Some TPAs resist independent review of their adjudication work. Three workarounds:
1. Contractual authority. Most ASO agreements give the employer the right to audit claims and direct data extracts. The employer's ERISA counsel reviews the ASO contract and issues the cooperation letter citing the specific audit clause. The TPA is the employer's vendor, not the other way around.
2. Alternative data path. If the TPA will not provide a hold-window extract, the employer can pull claims data from its own reporting portal (most TPAs provide employer-facing dashboards with claim-level detail) and route it to Caliber. Review happens in parallel with TPA processing. Findings are delivered to the employer, who can request adjustments on already-paid claims through the TPA's standard dispute process. Less efficient, but functional.
3. Contract renewal leverage. If the TPA refuses both options, that refusal becomes a data point for the employer's next ASO renewal. An administrator that will not allow independent billing verification is telling the employer something about its own confidence in its adjudication accuracy.
Required Data Elements per Claim
| Field | Format | Purpose |
|---|
| Claim ID | TPA-assigned | Unique identifier for tracking through BGS workflow |
| Billed amount | USD, 2 decimals | Threshold determination, rate evaluation |
| Diagnosis codes | ICD-10-CM | CODEVAL accuracy, medical necessity review |
| Procedure codes | CPT / HCPCS | CODEVAL, BUNDLEVAL, rate comparison |
| Revenue codes | UB-04 (facility only) | Facility charge verification, room & board accuracy |
| Provider NPI | 10-digit NPI | CREDVAL — license, board cert, exclusion check |
| Service dates | YYYY-MM-DD | DURVAL — LOS review, DUPCHECK date matching |
| Admission/discharge dates | YYYY-MM-DD (inpatient) | Length of stay calculation, DRG validation |
| Plan terms | Fee schedule / contract ref. | RATEVAL — contracted rate comparison |
| DRG (if applicable) | MS-DRG / APR-DRG | RATEVAL — DRG weight and payment accuracy |
04 · The Seven-Check Billing Governance Standard
BGS v1.0 — Seven checks. Four determinations.
Every claim, every time.
Each claim above threshold receives all seven checks. No sampling. No random selection. Every claim, verified against independent data sources, by credentialed reviewers. The BGS produces one of four determinations: Verified (clean), Adjust (findings requiring employer review), Hold (material discrepancy requiring investigation), or Escalate (potential fraud indicators requiring formal referral).
The determinations are advisory. Caliber never issues payment instructions. The employer receives the findings and decides.
Check 01 · CODEVAL
Code Accuracy Verification
ICD-10-CM diagnosis code accuracy: Are the reported diagnosis codes clinically consistent with the documented services? Do they meet specificity requirements under ICD-10 coding guidelines?
CPT/HCPCS procedure code accuracy: Are the procedure codes correct for the services rendered? Are modifier codes applied correctly (e.g., -59 for distinct procedural services, -25 for significant E/M)?
Bundling compliance: Initial screen for procedures that should be bundled under a single code per CCI edits (detailed unbundling analysis in BUNDLEVAL).
Sources: AMA CPT Professional Edition 2026; WHO ICD-10-CM Official Guidelines; CMS National Correct Coding Initiative Edits (https://www.cms.gov/medicare/coding-billing/national-correct-coding-initiative-edits)
Check 02 · DUPCHECK
Duplicate Claim Identification
Cross-references the claim against all prior claims within a rolling 12-month window. Matches on: member ID, service dates, procedure codes, provider NPI, and facility. Identifies exact duplicates (same claim resubmitted), near-duplicates (same services billed by different providers for the same date), and split-billing patterns (single episode fragmented across multiple claims to avoid detection).
Source: OIG Work Plan 2025 identifies duplicate billing as a persistent overpayment driver (https://oig.hhs.gov/reports-and-publications/workplan/). AHLA estimates 3–5% of commercial claims contain duplicate charges.
Check 03 · RATEVAL
Rate Verification
Contracted rate verification: Is the billed amount consistent with the provider's contracted rate with the TPA/network? Requires plan terms data from employer.
UCR benchmark comparison: How does the billed amount compare to usual, customary, and reasonable (UCR) rates for the same procedure, same geography? Flagged if billed amount exceeds 150% of UCR.
Medicare reference pricing: What would Medicare pay for the same service? Commercial-to-Medicare ratio calculated. Flagged if ratio exceeds 300% (national commercial average is 224% per RAND).
Sources: CMS Medicare Fee Schedules (https://www.cms.gov/medicare/payment/fee-schedules); RAND Hospital Price Transparency Study 2024; FAIR Health UCR database.
Check 04 · DURVAL
Duration and Utilization Review
Length of stay review: Does the billed length of stay align with clinical guidelines for the reported DRG and diagnosis? Geometric mean LOS (GMLOS) comparison using CMS MedPAR data.
Service frequency: Are the billed services consistent with expected utilization patterns? Flags excessive imaging frequency, daily therapy units above clinical norms, and ancillary service volumes that exceed peer benchmarks.
Level of care: Was the billed level of care (ICU vs. step-down vs. med-surg) consistent with the clinical acuity documented in the diagnosis codes?
Sources: CMS MedPAR GMLOS tables; Milliman Care Guidelines; InterQual criteria (if licensed by employer).
Check 05 · CREDVAL
Provider Credential Verification
Active license verification: Is the billing provider's medical license active and in good standing in the state where services were rendered? Checked against state medical board databases.
Board certification: Does the provider hold board certification relevant to the services billed? A podiatrist billing for cardiac catheterization is a flag.
NPI validation: Is the NPI active? Does the NPI match the provider name and taxonomy code? Checked against NPPES (National Plan and Provider Enumeration System). Also screens against OIG exclusion list (LEIE) and SAM.gov debarment database.
Sources: NPPES NPI Registry (https://npiregistry.cms.hhs.gov/); OIG LEIE (https://oig.hhs.gov/exclusions/); SAM.gov; State medical board databases.
Check 06 · SVCVAL
Service Validation
Service rendered verification: Triggered review — applied when CODEVAL, RATEVAL, or DURVAL produce flags. Requests supporting documentation (operative notes, discharge summary, pathology reports) to confirm that the billed service was actually performed as coded.
Medical necessity review: Does the documented clinical presentation support the medical necessity of the billed service? Applied using established medical necessity criteria. This check may require clinical reviewer (MD/DO) input for complex cases.
SVCVAL is a triggered check, not a universal screen. Applied to approximately 15–25% of reviewed claims based on findings from other checks. Source: AHLA Compliance Guidelines; OIG Advisory Opinions.
Check 07 · BUNDLEVAL
Unbundling Detection
CCI edit compliance: Screens all procedure code pairs against the CMS National Correct Coding Initiative (NCCI) edit tables. Identifies procedure pairs that should be bundled — billed as a single code, not separately.
Facility vs. professional overlap: Identifies charges billed on both the facility (UB-04) and professional (CMS-1500) claim for services that should appear on only one. Common in surgical episodes where the facility bills a global surgical package and the surgeon separately bills components already included.
Component billing detection: Identifies lab panels billed as individual tests, imaging studies billed as separate components, and multi-procedure discounts not applied.
Source: CMS NCCI Edits (https://www.cms.gov/medicare/coding-billing/national-correct-coding-initiative-edits); updated quarterly. OIG estimates unbundling accounts for 1.5–3% of total commercial claim dollars.
These seven checks are not aspirational. They map directly to the verification protocols that ClearBill used to return $9.2M to payers in its first six months of full deployment. Same methodology. Same reviewer credentials. Different buyer.
05 · Workflow
Claim in, certificate out. Ten business days.
The workflow is linear. No decision trees. No committee reviews. One claim enters, one Billing Governance Certificate exits. The employer receives findings and decides. Caliber never issues payment instructions to the TPA.
01
TPA transmits claim. Weekly or daily extract of claims in hold status above $25K threshold. Secure file transfer (SFTP) or encrypted email. Claim enters Caliber's intake log with timestamp and unique tracking ID.
02
Claim logged and categorized. Claim type (facility/professional/pharmacy), billed amount, and complexity score assigned. Complexity score determines reviewer assignment — routine claims to CPC, complex facility claims to CCS, medical necessity questions flagged for clinical reviewer queue.
03
Assigned to credentialed reviewer. One reviewer per claim. Reviewer credentials (CPC, CCS, or RHIA) matched to claim type. Reviewer has no prior relationship with the billing provider. Conflict of interest screen on every assignment.
04
Seven checks executed. CODEVAL, DUPCHECK, RATEVAL, DURVAL, CREDVAL applied to every claim. SVCVAL triggered if findings from other checks warrant documentation review. BUNDLEVAL applied to all claims with multiple procedure codes. Each check produces a pass or flag with supporting narrative.
05
Clinical review (if triggered). Claims flagged for medical necessity, level-of-care questions, or complex coding disputes are escalated to the clinical reviewer (MD/DO). Clinical reviewer issues an independent opinion within 3 business days. Approximately 10–15% of reviewed claims require clinical escalation.
06
Findings documented. Reviewer completes the Billing Governance Certificate with: determination (Verified/Adjust/Hold/Escalate), findings narrative for each flagged check, recommended action, and quantified discrepancy amount where applicable.
07
BGC issued to employer. Certificate transmitted to employer's designated benefits contact via secure portal or encrypted email. Includes claim ID, billed amount, all seven check results, and reviewer credentials. Not sent to TPA or provider. The employer controls the findings.
08
Employer reviews and decides. Employer reviews BGC findings within the remaining hold window. For claims with flags (Adjust/Hold/Escalate), the employer directs the TPA before the hold window expires. Clean claims (Verified) can be released immediately upon BGC delivery. If the remaining hold window is insufficient for employer review, the employer can extend the hold on individual flagged claims — this is within the employer's fiduciary authority. Most employers designate a single benefits contact with standing authority to act on BGC findings within 2–3 business days.
09
Claim released or adjusted. Employer directs the TPA. Caliber never contacts the TPA directly. The employer's fiduciary authority governs the payment decision. Caliber logs the outcome for scorecard reporting.
10
Quarterly sealed report. Every quarter, Caliber issues a sealed aggregate report: total claims reviewed, discrepancy rate, total prevented overpayment, turnaround times, false positive rate, and trend analysis. This report is the employer's governance documentation for fiduciary compliance.
10 days
Standard turnaround: claim receipt to BGC delivery
5 days
Expedited turnaround for short-hold TPAs (<14 day window)
2–3 days
Typical employer decision time after BGC delivery
06 · Timeline
Fastest pilot in the portfolio.
Operational in 30 days.
Caliber has no technology integration, no member-facing component, and no network negotiation. At pilot scale, it runs on credentialed reviewers, spreadsheets, and secure email. The only dependency is TPA cooperation on the claims feed. Most TPAs comply within one billing cycle.
Week 1
Agreement and BAA. Pilot agreement signed. BAA executed. Employer issues TPA cooperation letter. Caliber assigns account lead and begins reviewer recruitment/assignment.
Week 2
TPA onboarding. TPA acknowledges cooperation letter. Data format confirmed (837 vs. CSV). SFTP credentials exchanged or encrypted email protocol established. Test file transmitted and validated.
Week 3
Baseline analysis. Historical claims data (prior 6–12 months) reviewed to establish baseline discrepancy expectations. Volume projections calibrated. Reviewer capacity confirmed. Scorecard metrics finalized with employer.
Week 4
Go-live. First live claims extract received. Claims enter BGS workflow. First Billing Governance Certificates issued within 10 business days of claim receipt.
Week 5–8
Steady-state operations. Weekly claims intake. BGCs issued on rolling basis. 30-day scorecard delivered to employer at end of Week 8. First findings reviewed with employer. Workflow refinements based on volume and complexity patterns.
Week 9–12
Measurement and decision. 60-day scorecard delivered at Week 12. Aggregate findings report. Discrepancy rate, prevented overpayment total, turnaround time performance, and false positive rate calculated. Pilot review meeting with employer.
Week 13
Decision point. 90-day sealed scorecard. Full pilot results. Employer decides: continue to full contract, expand scope (add $10K–$25K tier), or walk away. No penalty. No termination fee. Employer keeps all data and findings from pilot period.
Most healthcare pilots take 6–9 months to launch. Caliber is operational in 30 days because there is nothing to build. The methodology exists. The reviewer credentials exist. The TPA hold window exists. We are connecting existing infrastructure with independent verification.
07 · Staffing
Credentialed reviewers. Not employees.
Contracted through coding agencies.
Caliber does not require a standing workforce. Reviewers are credentialed coding professionals contracted through established medical coding agencies. This keeps fixed costs near zero during pilot and allows capacity to scale linearly with volume.
Reviewer Credentials
| Credential | Issuing Body | Role in BGS | Hourly Range |
|---|
| CPC (Certified Professional Coder) | AAPC | Primary reviewer for professional claims. CODEVAL, BUNDLEVAL, DUPCHECK. | $28–$45 |
| CCS (Certified Coding Specialist) | AHIMA | Primary reviewer for facility/inpatient claims. DRG validation, LOS review, revenue code accuracy. | $32–$52 |
| RHIA (Registered Health Info. Admin.) | AHIMA | Senior reviewer. Complex claims, multi-check coordination, quality assurance on BGCs. | $40–$65 |
| MD/DO (Clinical Reviewer) | State medical board | Medical necessity review. Level-of-care disputes. SVCVAL clinical opinions. Approximately 10–15% of claims. | $125–$200 |
Capacity Planning
| Monthly Claims Volume | CPC/CCS Reviewers | Clinical Reviewer Hours | Est. Monthly Reviewer Cost |
|---|
| 15–25 claims | 1 part-time | 4–8 hrs | $3,500–$5,500 |
| 30–50 claims | 1 full-time | 8–12 hrs | $6,000–$9,000 |
| 75–125 claims | 2–3 | 16–24 hrs | $14,000–$22,000 |
| 150–250 claims | 3–5 | 24–40 hrs | $24,000–$42,000 |
| 300–500 claims | 6–10 | 48–80 hrs | $48,000–$82,000 |
Reviewer cost estimates assume 2–3 hours per claim for full 7-check BGS review. Complex claims (surgical episodes, multi-day stays) trend toward 3 hours. Straightforward claims (single procedure, clear coding) trend toward 1.5 hours. Clinical reviewer cost assumes $150/hr midpoint. Source: AAPC 2024 Salary Survey; AHIMA Workforce Study 2024.
Sourcing
Reviewers are contracted through medical coding agencies with existing pools of credentialed professionals. No recruitment timeline. No benefits overhead. Agencies include: Aviacode, TrustHCS, Omega Healthcare, AGS Health, and regional coding firms. Minimum requirement: 3 years post-credential experience, active credential status, no OIG exclusions, and successful completion of Caliber's BGS training module (4 hours, self-paced).
08 · Technology
At pilot scale: spreadsheet and secure email.
At scale: purpose-built intake portal.
Caliber's pilot does not require technology. This is a deliberate design decision. The value is in the methodology and the reviewer credentials, not in software. Technology layers on as volume justifies it.
Pilot Scale
Manual workflow — 15–50 claims/month
Claims received via SFTP or encrypted email. Logged in a structured spreadsheet (claim tracking, reviewer assignment, check status, findings, BGC status). BGC generated as a formatted PDF from a template. Secure email delivery to employer. Total technology cost: $0.
Growth Scale
Semi-automated — 50–200 claims/month
Claims intake portal for TPA file uploads. Automated claim parsing (837 → structured data). CCI edit database integration for automated BUNDLEVAL pre-screening. BGC PDF generator with auto-populated fields. Reviewer dashboard for assignment and tracking. Estimated build cost: $15K–$30K.
Enterprise Scale
Fully automated checks + human review — 200+ claims/month
Automated CODEVAL (code validation against ICD-10/CPT databases), automated DUPCHECK (cross-claim matching), automated CREDVAL (NPI registry API, OIG LEIE API). Human reviewers focus on RATEVAL, DURVAL, SVCVAL — the checks that require clinical judgment. Estimated build cost: $75K–$150K.
Data Sources
Reference databases — all tiers
CMS CCI edit database (free, quarterly updates). NPPES NPI Registry (free API). OIG LEIE (free, monthly updates). CMS Medicare Fee Schedules (free). FAIR Health UCR database (licensed, ~$5K–$15K/year depending on volume). State medical board databases (free, varies by state).
CCI edits: https://www.cms.gov/medicare/coding-billing/national-correct-coding-initiative-edits
Medicare fee schedules: https://www.cms.gov/medicare/payment/fee-schedules
The pilot proves the methodology. The technology accelerates it. Building software before proving the value proposition is the mistake most health tech companies make. Caliber proves value first, then automates.
09 · Scorecard
Five metrics. Defined before launch.
Measured against your own data.
The scorecard is the decision document. Every metric has a definition, a data source, and a target. The employer agrees to the metrics before the pilot starts. We do not choose our metrics after seeing the results.
| Metric | Definition | Source | Pilot Target |
|---|
| Discrepancy rate |
Percentage of reviewed claims with at least one flagged check (Adjust, Hold, or Escalate determination) |
BGC outcomes log |
4–6% |
| Prevented overpayment |
Total dollar amount of billing discrepancies identified and accepted by employer (claims adjusted or held based on BGC findings) |
BGC findings + employer disposition log |
Variable* |
| Turnaround time |
Business days from claim receipt to BGC delivery. Measured as mean and P95. |
Intake timestamp vs. BGC delivery timestamp |
≤10 days (mean)
≤14 days (P95) |
| False positive rate |
Percentage of flagged claims where employer rejects the finding and releases claim for payment as-is |
Employer disposition log |
<15% |
| Claim mix |
Distribution of reviewed claims by type: facility inpatient, facility outpatient, professional, pharmacy. Reported for transparency. |
Intake log categorization |
Reported only |
*Prevented overpayment target is set during baseline analysis based on employer's historical claim volume above threshold. At a 4% discrepancy rate on claims averaging $40K billed amount with 30 claims/month, expected prevented overpayment is approximately $48K/month ($576K annualized). Actual results depend on employer's specific claim mix and provider billing patterns. Methodology note: RATEVAL flags are counted as prevented overpayment only when the billed amount exceeds the provider's contracted rate — not merely when it exceeds Medicare or UCR benchmarks. A high commercial-to-Medicare ratio is an informational flag, not an overpayment, unless it violates the contract.
Scorecard Cadence
Day 30
Preliminary scorecard. First month's claims reviewed. Volume calibration. Initial discrepancy rate. Workflow refinements documented.
Day 60
Interim scorecard. Two months of data. Discrepancy trends emerging. Prevented overpayment running total. False positive rate calculated. Turnaround time performance.
Day 90
Final sealed scorecard. Full pilot results. Decision document. Includes trend analysis, ROI calculation, and recommendation for full contract scope.
10 · Economics
The pilot costs a rounding error.
The recovery is material.
Two pricing models. The pilot uses PEPM only. The full contract adds an overpayment share that aligns incentives — Caliber earns more when it finds more, and the employer keeps the majority of every dollar recovered.
Pilot Pricing
$3 PEPM
Flat rate during 90-day pilot
No overpayment share during pilot. No setup fees. No implementation charges. Caliber absorbs all reviewer costs and overhead during pilot. The $3 PEPM covers the review, the BGCs, the scorecards, and the sealed quarterly report.
Full Contract Pricing (Post-Pilot)
| Covered Lives | PEPM | Overpayment Share | Employer Keeps |
|---|
| <10,000 | $4–5 | 17.5% | 82.5% |
| 10,000–25,000 | $3–4 | 17.5% | 82.5% |
| 25,000–50,000 | $3.50–4 | 15% | 85% |
| 50,000+ | $3–3.50 | 15% | 85% |
ROI by Employer Size
At a 4% discrepancy rate on claims above $25K, with an average flagged claim discrepancy of $8,000–$12,000.
| Covered Lives | Est. Annual Claims >$25K | Flagged (4%) | Est. Annual Recovery | Annual PEPM Cost | Net ROI |
|---|
| 10,000 | 480 | 19 | $152K–$228K | $480K | See note* |
| 25,000 | 1,200 | 48 | $384K–$576K | $900K | See note* |
| 50,000 | 2,400 | 96 | $768K–$1.15M | $1.5M | See note* |
| 100,000 | 4,800 | 192 | $1.54M–$2.3M | $2.4M | See note* |
| 250,000+ | 12,000 | 480 | $3.84M–$5.76M | $6M | See note* |
*Recovery figures shown are gross, before the 15–17.5% overpayment share that applies post-pilot. PEPM cost covers the full governance layer — verification, BGCs, scorecards, sealed quarterly reports, and fiduciary documentation. The PEPM is not exclusively tied to overpayment recovery; it buys billing governance as a standing capability. At a conservative 4% discrepancy rate, recovery alone does not exceed PEPM cost for most employer sizes. At the 5–10% discrepancy rates that OIG and AHLA data suggest for certain claim types (facility inpatient, surgical episodes), net positive ROI on recovery alone is achievable. The PEPM also buys deterrence: providers who know claims are being independently verified bill more accurately over time. Source: OIG Semiannual Report to Congress, FY2024 (https://oig.hhs.gov/); AHLA Health Law Compliance Series 2024.
Our Cost to Run
Reviewer Fees
$35–$50/hr blended rate for CPC/CCS. 2–3 hours per claim. Primary cost driver at pilot scale.
Clinical Reviewer
$125–$200/hr. Applied to 10–15% of claims. Part-time at pilot scale. Monthly cost: $500–$2,400 depending on volume.
Overhead
Account management, QA, data handling, BGC production, scorecard generation. Estimated 20–25% markup on direct reviewer costs.
11 · Billing Governance Certificate
The deliverable. One certificate per claim.
Every reviewed claim produces a Billing Governance Certificate. The BGC is the employer's record of independent verification. It documents what was checked, what was found, and what action is recommended. The employer uses it to direct the TPA.
Claim Type
Facility Inpatient (837-I)
Service Dates
2026-05-12 through 2026-05-17
Provider NPI
1234567890 — Metro Regional Medical Center
Determination
ADJUST — Findings Require Employer Review
Seven-Check Results
RATEVAL
FLAG — Billed at 312% of Medicare. UCR exceeded.
DURVAL
FLAG — LOS 5 days vs. GMLOS 3.2 for DRG 470.
SVCVAL
TRIGGERED — Documentation requested.
Findings Narrative
Billed amount of $87,342 represents 312% of Medicare allowable for DRG 470 (Major Hip and Knee Joint Replacement). UCR for same procedure in this market is $62,100–$71,400 (FAIR Health, 80th percentile). Additionally, billed LOS of 5 days exceeds the GMLOS of 3.2 days for this DRG. Supporting documentation requested to verify clinical necessity of extended stay. If LOS is adjusted to GMLOS and rate aligned to contracted terms, estimated appropriate charge is $64,200–$72,800.
Recommended Action
Hold for employer review. Request operative notes and daily progress notes for days 4–5 from provider to verify clinical necessity of extended stay. If documentation does not support extended LOS, recommend adjustment to contracted rate at GMLOS. Estimated discrepancy: $14,500–$23,100.
Reviewer
J. Martinez, CCS, RHIA · 8 years experience
Certificate Date
2026-06-02
This is a sample BGC for illustration. Actual certificates include full coding detail, reference rate tables, and source citations for each flagged check. BGCs are retained for 7 years per ERISA recordkeeping requirements.
12 · Escalation to Full Contract
The pilot proves it. The contract scales it.
The pilot is designed to answer one question: does independent pre-payment verification find material billing discrepancies in your claims? If the 90-day scorecard demonstrates a discrepancy rate above 2% and prevented overpayment exceeds the PEPM cost, the value case is proven on your own data.
Pilot to Full Contract: What Changes
| Dimension | Pilot | Full Contract |
|---|
| Pricing | $3 PEPM flat | Tiered PEPM ($3–5) + 15–17.5% overpayment share |
| Threshold | >$25K only | >$25K full BGS + optional $10K–$25K coding-only tier |
| Claim types | Facility + professional | Facility + professional + specialty pharmacy |
| Reporting | Scorecards at 30/60/90 days | Monthly BGC summary + sealed quarterly report |
| Technology | Spreadsheet + secure email | Claims intake portal + automated pre-screening |
| Term | 90 days, walk-away | 12-month initial, auto-renew, 90-day termination notice |
| Dispute resolution | Employer decides, no formal process | 10-day employer review + independent third-party arbiter |
Expansion Paths
Add $10K–$25K Coding Tier
Apply CODEVAL and BUNDLEVAL to claims between $10K and $25K. Increases reviewed volume by 3–5x. Catches the high-frequency coding errors that fall below the full-verification threshold.
Add Specialty Pharmacy
Biologics, gene therapy, and specialty infusions above $25K. These claims have the highest per-unit cost and the most complex billing. Pharmacy CODEVAL includes NDC verification, J-code accuracy, and waste/discard billing compliance.
Provider Deterrence Reporting
Quarterly aggregate report identifying providers with above-average flag rates. Not punitive. Provides the employer's benefits team with visibility into which provider relationships produce the most billing discrepancies. Gives the benefits team real data for network decisions.
13 · Legal Positioning
Advisory-only. The most important
two words in this document.
Caliber never denies a claim. This is the critical legal distinction. Caliber verifies and advises. The employer decides. The employer directs the TPA. Caliber's findings are a governance input, not a payment decision. This positioning has three specific legal consequences.
Advisory-Only Positioning
Not a utilization review organization
Caliber does not make coverage determinations. Caliber does not apply medical necessity criteria to deny benefits. Caliber does not contact providers, members, or the TPA directly. Caliber reviews billing accuracy and reports findings to the employer. This distinction matters: state utilization review licensing statutes typically define UR as the process of determining medical necessity or appropriateness of coverage. Billing accuracy verification — confirming that codes, rates, and credentials match the claim — falls outside that definition in most jurisdictions. Caliber also does not trigger ERISA adverse benefit determination notice requirements because it does not deny benefits. The employer retains full fiduciary authority over the payment decision.
Legal basis: ERISA § 503 (adverse benefit determination procedures apply to claim denials, not billing verification). State UR licensing: varies by state; advisory billing review without coverage determination is generally excluded from UR definitions. Consult employer's ERISA counsel for jurisdiction-specific confirmation.
Fiduciary Safe Harbor
Self-funded employers have an ERISA fiduciary duty to administer the plan prudently. Independent billing verification demonstrates prudent oversight of plan assets. The BGC and sealed quarterly report create a documented governance record. In the event of a fiduciary challenge, the employer can demonstrate that high-cost claims were independently verified before payment. This is affirmative evidence of fiduciary diligence, not a liability.
Business Associate Agreement
Caliber operates under a standard HIPAA BAA as a business associate of the employer (not the TPA). PHI is limited to claims data elements necessary for verification. No member contact information, no clinical notes (unless requested under SVCVAL), no SSNs. Data encrypted in transit (TLS 1.3) and at rest (AES-256). Retention: 7 years per ERISA recordkeeping requirements. Breach notification: per HHS Breach Notification Rule (45 CFR §§ 164.400–414).
Data Security
Claims data transmitted via SFTP or encrypted email (minimum TLS 1.2). Stored in access-controlled environment with audit logging. Reviewer access limited to assigned claims only — no reviewer sees the full claims book. Annual security assessment. SOC 2 Type II certification targeted for year two of operations. At pilot scale, data handling follows NIST Cybersecurity Framework controls for PHI (NIST SP 800-171).
14 · Data Sources and References
Every check references an independent source.
Nothing is proprietary opinion.
Caliber's verification methodology relies on publicly available, independently maintained data sources. No proprietary black-box algorithms. Every finding can be traced to a published reference.
| Source | Used In | Access |
|---|
| CMS National Correct Coding Initiative (NCCI) Edits |
BUNDLEVAL — procedure pair edit tables, modifier indicators, mutually exclusive codes |
cms.gov/ncci-edits — free, updated quarterly |
| CMS Medicare Fee Schedules |
RATEVAL — Medicare reference pricing, commercial-to-Medicare ratio calculation |
cms.gov/fee-schedules — free, updated annually |
| OIG (Office of Inspector General) |
CREDVAL — LEIE exclusion list. General — OIG Work Plan identifies billing risk areas. |
oig.hhs.gov — LEIE updated monthly, Work Plan annual |
| NPPES NPI Registry |
CREDVAL — NPI validation, provider taxonomy, practice location |
npiregistry.cms.hhs.gov — free API |
| FAIR Health |
RATEVAL — UCR benchmarks by procedure, geography, and provider type |
Licensed database — $5K–$15K/year by volume tier |
| CMS MedPAR / GMLOS Tables |
DURVAL — geometric mean length of stay by DRG |
CMS public use files — free, updated annually |
| AHLA (American Health Law Association) |
General — compliance guidance, billing fraud indicators, employer governance best practices |
Member publications — referenced for methodology validation |
| MGMA Benchmarks |
RATEVAL — physician compensation and production benchmarks by specialty |
Licensed database — referenced for rate reasonableness |
| State Medical Board Databases |
CREDVAL — active license verification, disciplinary actions, practice restrictions |
Varies by state — most free, some require registration |
| SAM.gov (System for Award Management) |
CREDVAL — federal debarment and exclusion screening |
sam.gov — free, real-time search |
| AMA CPT Professional Edition |
CODEVAL — procedure code definitions, modifier guidelines, coding instructions |
Licensed publication — standard reference for all credentialed coders |
| RAND Hospital Price Transparency Study |
RATEVAL — commercial-to-Medicare price ratios by hospital, state, and service line |
Published research — free, updated periodically |
| State Insurance Department Guidelines |
General — state-specific billing regulations, balance billing protections, prompt pay requirements |
Varies by state — free, published by state DOI |