Wake-Up Brief
They Didn't Audit The Codes. They Audited The Workflow.
The largest Medicare Advantage False Claims Act settlement on record is not a coding case. It is a workflow case. Every integrated system using retrospective chart review should read this before Monday.
- Why the $556M Kaiser settlement reframes the compliance question for every Medicare Advantage organisation
- Eight-question scorecard for testing your own addenda workflow.
What's inside
What's Inside the Brief.
Six pages. The reframe, the industry pattern, the scorecard, and the references.
The Foreword
From the desk of the founder. Why the compliance question has quietly moved one layer up — from whether your codes are defensible to whether your workflow is defensible as a workflow.
The Reframe
A coding case, read as a workflow case. The Justice Department complaint did not allege Kaiser submitted the wrong codes; it alleged that the sequence itself was the violation.
The Four-Step Sequence
The four operational steps the government named: mining charts, generating targeted queries, tying compensation to diagnosis-addition targets, and adding addenda months or years after the original visit.
The Industry Pattern
Not a Kaiser practice — an industry practice. Where UnitedHealth Group, Cigna, and Aetna / Elevance / Humana stand in the enforcement record. Plus the bipartisan Senate Finance Committee finding.
The Workflow Scorecard
Eight questions to take into your next compliance review. Provenance, lag, trigger, incentive, symmetry, internal flags, clinical justification, workflow-level visibility. If three or more answers are uncertain, the workflow is the audit target.
References & Sources
Six primary sources behind the brief — DOJ press release, STAT News, Fierce Healthcare, Arnall Golden Gregory, Senate Committee on Finance, and the Wall Street Journal.
Why RapidClaims
The Workflow Is The Audit Target. RapidClaims Is The Workflow Layer.
The Brief says it directly: compliance is no longer a coding question. It is a workflow question. RapidClaims runs the layer where the workflow becomes defensible — validating every E/M and HCC claim against AMA 2021 MDM and risk-adjustment criteria at submission, surfacing addenda triggered by automated systems rather than clinical need, and leaving the audit trail a regulator can follow without reconstruction.
>95%
Coding accuracy
Across 25+ specialties, including the complex ones competitors avoid.
40%
Fewer denials
Documentation gaps caught at the point of code, before submission.
25+
Specialties supported
Depth in the hardest specialties, not just the easy volume.
82.5%
Charts auto-coded
Autonomous at an enterprise-grade accuracy threshold.
1.7×
Coder productivity
More charts per coder — without adding a single FTE.
6 wks
To go-live
From signed agreement to live coding in your environment.
Results
Capture every dollar of earned revenue
Built for Healthcare. Secured for Enterprise.
SOC 2 Type II
Independently audited security controls
HIPAA
Full adherence to healthcare privacy standards
HITRUST Ready
Aligned with healthcare's most rigorous framework
256-bit Encryption
Data encrypted at rest and in transit