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This didn't exist three years ago.

A new capability in public healthcare spending. Here are the outcomes it produces. Then you tell us whether they're worth having.

Experience it in 3D →

What changed

Two things shifted. Together they created something that wasn't possible before.

Almost no state has used it yet — not because it doesn't work, but because it's new.

One

The State can now demand its own claims data.

  • The Consolidated Appropriations Act, 2021 — Division BB, Title II, §201 — added Internal Revenue Code §9824, ERISA §724, and Public Health Service Act §2799A‑9.1
  • Those provisions bar a plan from entering into an agreement with a provider, network, third‑party administrator, or other service provider that restricts the plan's access to its own cost, quality, and claims information.2
  • Federal guidance is explicit that a restrictive provision in a TPA contract is a prohibited gag clause.3
  • It goes further: limiting claims‑data access to audit‑only purposes, capping how often it can be accessed, requiring it be viewed on the vendor's premises, or making access subject to vendor approval are all prohibited.4
  • PHS Act §2799A‑9 is the operative provision for State employee plans. This is not only a private‑employer rule.
  • Plans must attest compliance annually. The first attestations came due in December 2023.2

The data was always the State's. Until 2023, the contracts said otherwise.

Two

Every claim can now be examined — not sampled.

  • Sampling was never a preference. It was a capacity limit — reviewing millions of claims line by line was not operationally possible.
  • It is now.
  • For the first time, a case can be built claim by claim, provider by provider, dollar by dollar — rather than extrapolated from a few hundred records.
  • A sample tells you roughly what probably happened.
  • Every claim tells you exactly what did.

A sample produces an estimate. Every claim produces evidence.

The outcomes

What the State walks away with.

01

You know what your plan actually paid.

Every claim, every line, every dollar — across the State employee plan and Medicaid managed care.

02

You recover money.

Recovery typically runs in the range of 6% of annual claims spend — collected through settlement with the administrator that paid the claims. Not a new appropriation.

03

You have documented oversight.

A defensible record that the State examined its own spending — under a fiduciary standard that applies to public plans and is not waived by sovereign immunity.

04

Your findings are collectible.

Each one tied to a specific claim, a specific provider, and a specific amount. Provable rather than arguable.

05

You have ongoing visibility.

Continuous monitoring after the baseline — not one audit and then back to blind.

Proof

This is operational, not theoretical.

310M+ Lives analyzed to date
90 days To first findings
20+ Categories of fraud, waste, abuse, and error
100% Of claims reviewed — municipal proof of concept complete, findings delivered, endorsement on file

How it works

The State pays the claims. Someone else decides what they cost.

The old way

A sample.

A few hundred claims pulled, reviewed, and extrapolated across the whole population. The result is a projection — and a projection cannot be collected.

What's now possible

All of them.

Every claim examined at the transaction level. No sampling, no extrapolation, no simulation. Every finding attached to a real record with a real dollar figure behind it.

Illustrative — each panel represents 1,000 claim records. Actual plan volume runs into the millions.

A sample is audit theater. You cannot recover an extrapolation.

If those outcomes are valuable to your office, we'll show you what they look like on your own data.

Sources

  1. Consolidated Appropriations Act, 2021, Division BB, Title II (Transparency), §201 — adding Internal Revenue Code §9824, ERISA §724, and Public Health Service Act §2799A‑9. congress.gov/bill/116th-congress/house-bill/133/text
  2. Centers for Medicare & Medicaid Services, Gag Clause Prohibition Compliance Attestation. cms.gov — Gag Clause Prohibition Compliance
  3. Departments of Labor, Health and Human Services, and the Treasury, FAQs About Affordable Care Act and Consolidated Appropriations Act, 2021 Implementation, Part 57. cms.gov/files/document/aca-part-57.pdf
  4. Gag clause compliance guidance summarizing prohibited restrictions on de‑identified claims data — including audit‑only limitations, frequency caps, on‑premises‑only review, and vendor‑discretion approval gates.
  5. Transparency in Coverage final rule — machine‑readable file disclosure requirements for in‑network negotiated rates and out‑of‑network allowed amounts.
  6. Employee Retirement Income Security Act §404(a) (prudent management of plan assets) and §104(b)(4) (participant and sponsor right to plan documents). dol.gov/general/topic/health-plans/erisa

Recovery figures reflect typical results across prior engagements and are not a guarantee of outcome for any specific plan. Nothing in this document constitutes legal advice.