caliber
billing governance
c
Every public company audits its books.
No self-funded employer audits its claims.
No self-funded employer audits its claims.
Measure twice.
Joe Nalley — Founder
Executive Briefing — April 2026
The Problem
The TPA processes your claims.
The TPA edits your claims.
The TPA pays your claims.
The TPA edits your claims.
The TPA pays your claims.
Processor, editor, and auditor. Same entity. Nobody independently verifies that what was billed matches what was delivered. Your TPA already holds high-cost claims for 14-60 days before releasing payment. During that hold, the verification step is empty.
4-6%
Documented billing inaccuracy
on high-cost claims (OIG, AHLA, MGMA)
on high-cost claims (OIG, AHLA, MGMA)
$0.25
Recovered for every $1 of
overpayment found retrospectively
overpayment found retrospectively
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The Solution
Caliber fills the hold window
with independent verification.
with independent verification.
EXTRACT
Weekly claims extract from TPA. Eight data fields. No integration.
→
VERIFY
Seven checks by external credentialed reviewers. 5-10 business days.
→
RETURN
Verified, Adjust, Hold, or Escalate. Line-item detail. You decide.
→
CERTIFY
Billing Governance Certificate. Quarterly. Sealed. Board-ready.
Advisory-only. Caliber never contacts providers. Never communicates with members. Never issues payment instructions. We verify the bill. You decide what to do about it.
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The Seven Checks
What we verify on every claim
above threshold.
above threshold.
CODEVAL
Coding accuracy
DUPCHECK
Duplicate detection
RATEVAL
Rate verification
DURVAL
Duration verification
CREDVAL
Credential verification
SVCVAL
Service verification (triggered)
BUNDLEVAL
Bundle compliance
BGS v1.0 · External reviewers: CPC / CCS / RHIA · 3+ years experience
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The Deliverable
The Billing Governance Certificate.
Quarterly. Sealed. Versioned. Three audiences.
Sample Certificate Summary
Q1 2027 · Illustrative
94.2%
Verification Rate
5.8%
Discrepancy Rate
$416K
Prevented Overpayment
DURVAL
Top Finding Type
For your board.
Fiduciary evidence. Provider scores. Discrepancy distribution.
For stop-loss.
Verified claims above specific deductible. Different risk profile.
For renewal.
Trend analysis. TPA performance. A story nobody else can tell.
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The Independence Requirement
Five entities touch a high-cost claim.
None can independently verify it.
None can independently verify it.
TPA
Can't audit its own work. Throughput incentive, not accuracy.
Stop-loss carrier
Reviews for its own exposure. Not the employer's accuracy.
Provider
Can't verify its own billing. Revenue conflict.
Benefits consultant
Reports on spend. Doesn't verify individual claims.
The employer
A bank, a manufacturer, a retailer. No clinical billing expertise. Relies on the TPA. The TPA can't verify itself.
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The Economics
Prevention, not recovery.
$2-5
PEPM governance fee
Volume-tiered
Volume-tiered
$416K
Prevented overpayment
per 15K-life employer
per 15K-life employer
82.5%
Of prevented overpayment
stays with the employer
stays with the employer
90 days
Pilot term. Full BGS.
Walk away if it doesn't work.
Walk away if it doesn't work.
You're already paying for these claims. The question is whether anyone checks them before you do. The PEPM replaces unverified spend with governed spend. Stop-loss premium impact from documented billing governance is a second savings not modeled here.
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The Wedge
Every payment integrity company
sells to health plans.
sells to health plans.
Cotiviti, Optum, HMS. They optimize the plan's economics, not the employer's. They sell to the entity that processes the claim. Caliber sells to the entity that pays it.
RETROSPECTIVE AUDIT
Find errors after payment. Recover 50-70%. 12-18 months later. $1 spent recovering $0.25.
CALIBER
Verify before payment. Prevent the overpayment entirely. The full dollar stays. No disputes. No wait.
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The Platform
Part of a governance triad.
Cadence
Rx continuation governance
curated
BH episode governance
caliber
Billing governance
Same buyer. Same governance thesis. Three structural gaps. Together, they produce a Governance Portfolio for stop-loss renewal that doesn't exist anywhere else.
Currently onboarding first employer partners. Q3 2026.
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Joe Nalley
Founder · 200,000+ patients served
The Founder
I've been on both sides
of the claim.
of the claim.
- Built healthcare operations that processed millions in claims. BH, primary, urgent, surgical, imaging, lab.
- CEO, GetWell Health System. Multi-service health system through acquisition.
- Top-five national payer. Six high-acuity clinical books. I see what gets paid, what gets missed, and what nobody checks.
- The gap is fixable. The bill went through. Nobody checked. That's not fraud. It's a structural gap.
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caliber
billing governance
What did the bill
actually buy?
actually buy?
Independent pre-payment verification. Seven checks. Billing Governance Certificate. Measure twice.
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