A subset of your End-Stage Renal Disease (ESRD) members are almost certainly being reimbursed at the wrong CMS rate — often by thousands of dollars per member per month. We identify them, manage the full correction process, and recover the underpaid revenue. You don't lift a finger beyond the initial data pull.
ESRD members are reimbursed at a dramatically higher rate than standard members — but only when their status is properly established with CMS. For a meaningful share of members, it never is. The result is members quietly paid at the wrong rate, month after month, with nothing in your standard reporting to signal the gap. Catching it requires analytics purpose-built for this problem. That's what we do — and it's not something that surfaces in a standard internal review.
See how the gap compounds →We screen for every category of ESRD reimbursement gap — unestablished status, incorrect effective dates, transplant and graft transitions, and rate misapplication — each worth thousands per member per month.
The member is reimbursed at the wrong rate, every month.
Each uncaptured month adds to the recoverable total, up to the CMS window.
The longer a gap goes unaddressed, the more difficult and time-sensitive the recovery becomes.
Is the single biggest driver of how much you actually recover.
CMS allows retroactive recovery going back several years — but the opportunity erodes the longer a gap sits unaddressed. The plans that recover the most are the ones that move first.
Our process is fully managed and proprietary. You provide your data; we handle everything else — identifying the members, establishing what's owed, managing the correction end to end with the relevant parties, and tracking each dollar through to confirmed CMS recovery. Minimal internal lift required.
We ingest your data and surface the members who are being underpaid — using methods that go well beyond a standard reporting review.
We confirm each opportunity, establish the correct figures, and quantify what's recoverable within the CMS window.
We drive the full correction process with all required parties on your behalf — the part most plans can't execute internally, and the part that actually produces payment.
We track every adjustment through CMS and reconcile confirmed recovery against your records.
You keep 88% of money you didn't know you were owed.
Recoverable amounts vary by plan size and how long each gap has persisted — frequently reaching six or seven figures. We'll size yours during the free audit.
Our detection and recovery engine wasn't built in a lab. It was developed through direct collaboration with over 50 independent actuaries who specialize in Medicare Advantage rate-setting, ESRD population modeling, and CMS reconciliation. Their collective insight into where capitation gaps hide — and why they persist — is encoded into proprietary analytics that no standard audit tool replicates.
The result is a system purpose-built for one thing: finding ESRD revenue your plan is owed and recovering it through the exact CMS channels that produce payment.
Most internal reviews rely on the MMR at face value. Our analytics cross-reference claims data — dialysis procedures, session frequency, ESA utilization — against the ESRD flags on your MMR. Where claims show dialysis activity and the MMR shows no ESRD status, that's a recoverable gap. This type of cross-source detection is purpose-built and not something standard reporting surfaces.
We need your claims data and Monthly Membership Report (MMR) files. We handle all ingestion and parsing. The initial data pull is typically the only internal lift required — everything after that is fully managed on our side.
CMS allows retroactive corrections up to 84 months (7 years) back. This applies regardless of whether the member is still enrolled — recovery attaches to the months they were in ESRD status, not their current enrollment. The earlier you act, the more months fall within the window.
None. We charge 12% of confirmed recovered revenue — money CMS pays back to your plan. If we don't recover anything, you pay nothing. There are no retainers, setup fees, or minimum commitments. The free audit itself carries zero obligation.
All data is transferred via AES-256 encryption. We operate under HIPAA-compliant protocols and offer a Business Associate Agreement (BAA) before any data changes hands. Access is restricted to authorized personnel only, and we maintain SOC 2-aligned controls for data handling and storage.
The initial audit and discovery phase typically completes within the first few weeks. The full recovery timeline depends on the number of members identified and facility coordination required, but most plans see their first confirmed CMS recoveries within 60–90 days of engagement.
Share your details and we'll schedule a brief call to understand your plan's ESRD enrollment profile. We'll tell you whether there's an opportunity before you commit to anything.
We'll review your information and reach out within one business day to schedule your free revenue recovery audit.