The Aetna Asymmetry

$117.7 Million- and the lesson
isn't about Aetna

SCHEDULE A DEMOSPEAK TO AN EXPERT
Why One-Directional Chart Reviews Are Becoming a DOJ Liability
A practical field guide for provider organizations navigating Medicare Advantage, MSSP, ACO REACH, and risk-adjusted contracts — built from the DOJ’s theory in United States v. Aetna.
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What's Inside
Key findings, operational frameworks, and compliance safeguards included in this executive brief
The DOJ’s Structural Theory of Liability
Learn why selective submission — additions flowing to CMS while deletions are ignored — became the core issue in the Aetna settlement and a major DOJ enforcement focus.
Six Enforcement Patterns to Audit Immediately
Identify the risk-adjustment patterns most commonly flagged in DOJ investigations and OIG audits, from unsupported diagnoses to one-directional review workflows.
The 8 Chart Review Integrity Requirements
Explore the governance safeguards every chart review program needs, including deletion authority, audit trails, vendor accountability, and bi-directional review protocols.
Seven-Step Internal Risk Assessment
Use a practical assessment framework to evaluate unsupported-diagnosis risk, review high-RAF codes, and identify compliance gaps before the next submission cycle.
MEAT Documentation Standards That Hold Up in Audit
Understand how auditors apply Monitor, Evaluate, Assess, and Treat criteria — and why weak or single-element documentation is increasingly high risk.
Where denials stem from
60% to 70% of denials stem from coding errors, CDI gaps, and payer rule violations that happen before the claim is submitted
The real cost of denial recovery
Rework, write-offs, and cash flow drag that most finance teams don't measure
A 3-step prevention framework
Diagnose root causes, intervene upstream, and measure financial impact
Implementation roadmap
what to do in Week 1 - 12 to shift from recovery to prevention
Sample ROI calculation
See how a mid sized hospital saves over $5M annually just by preventing 35% of denials
Download the Guide
- WHY RAPIDCLAIMS

Built for the New Era of Risk - Adjustment Enforcement

RapidClaims helps provider organizations build compliant, audit-ready chart review workflows designed for today’s DOJ, CMS, and OIG scrutiny. From bi-directional review governance to documentation integrity, we help teams reduce risk before it becomes an enforcement issue.
>98%
Coding Accuracy
AI-verified codes with complete documentation for every chart processed.
40%
Fewer Claim Denials
Pre-submission scrubbing catches coding errors before they reach payers.
170%
Coder Productivity Increase
Your coders focus on complex cases while AI handles routine volume at scale.
70%
Cost Savings
Eliminate overtime, temp staffing, and recruitment costs with scalable AI.
>98%
Clean Claim Rate
See how a mid sized hospital saves over $5M annually just by preventing 35% of denials
30%
Reduction in AR Days
Faster coding turnarounds unlock millions in accelerated cash flow.
>98%
Coding Accuracy
AI-verified codes with complete documentation for every chart processed.
40%
Fewer Claim Denials
Pre-submission scrubbing catches coding errors before they reach payers.
170%
Coder Productivity Increase
Your coders focus on complex cases while AI handles routine volume at scale.
70%
Cost Savings
Eliminate overtime, temp staffing, and recruitment costs with scalable AI.
>98%
Clean Claim Rate
See how a mid sized hospital saves over $5M annually just by preventing 35% of denials
30%
Reduction in AR Days
Faster coding turnarounds unlock millions in accelerated cash flow.
Trusted by Leading Healthcare Organizations
Results You Can Trust
RapidClaims delivered what other vendors only promised. We've seen a 30% reduction in AR days within one quarter, unlocking $2.5M in accelerated cash flow. Their platform adapts to our specific workflows instead of forcing us to change our processes.
CFO, Major Health System
$2.5M
Accelerated cash flow
30%
Reduction in AR days
RapidRisk transformed our value-based care documentation, improving RAF by 15% and reducing documentation gaps by 22%. This directly impacts our shared savings and quality metrics.
Medical Director, Leading Accountable Care Organization
15%
↑ RAF
45%
New conditions identified
"With RapidClaims, we're maximizing our limited resources while improving revenue capture by 5%. Our team now spends more time on patient care and less on administrative tasks."
Director HIM, Federally Qualified Health Center
5%
↑ increased revenue
40%
Reduction in coding and billing costs
Our clean claim rate jumped from 92% to 99% with a 96% first pass yield rate. With RapidClaims, we improved the productivity of our coding staff by 100%. Our team only focuses on complex cases that require human expertise.
VP Revenue Cycle, Multi-Specialty Physician Group
27%
Reduction in claim denials
70%
Reduction in cost to collect
RapidRisk transformed our value-based care documentation, improving RAF by 15% and reducing documentation gaps by 22%. This directly impacts our shared savings and quality metrics.
Medical Director, Leading Accountable Care Organization
15%
↑ RAF
45%
New conditions identified
RapidClaims delivered what other vendors only promised. We've seen a 30% reduction in AR days within one quarter, unlocking $2.5M in accelerated cash flow. Their platform adapts to our specific workflows instead of forcing us to change our processes.
CFO, Major Health System
$2.5M
Accelerated cash flow
30%
Reduction in AR days
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