Case File · Start-up, Credentialing & Enrollment
Flagged by an algorithm, suspended — and reinstated.
An AI outlier model suspended a hospice agency's payments. We corrected the credentialing record, answered the finding, and got it reinstated to active billing.
Reinstated
Payment suspension lifted · reinstated to active billing
The challenge
A hospice agency was identified as a statistical outlier by an algorithmic program-integrity model and placed under payment suspension. The suspension stopped cash flow first; the burden then fell on the agency to respond — against the analytics that triggered it and against an enrollment record that had to be current and clean to support reinstatement.
Our approach
We worked the credentialing and revalidation record the way the contractor reads it — bringing enrollment, ownership, and managing-employee data current, closing the gaps that keep a suspension in place, and assembling the documentation that answered the outlier finding on its own terms. We profiled the billing pattern the way the integrity model does, so the response met the analytics rather than argued past them.
The impact
The agency was reinstated to active Medicare billing, with a credentialing and revalidation record built to stay current — so the same lapse can't reopen the door.