Caliber, LLC
Billing Governance Certificate
Pre-Payment Claims Verification · Certificate No. BGC-2026-SAMPLE
This certificate is issued to
[Redacted — Self-Funded Employer, ~15,000 lives]
Verification Period: Representative Year (12-month cycle)
BGC-2026-SAMPLE
Population Summary
Specimen Finding — Tolerance Gauge
Claim #A-2893 · NICU stay · billed vs verified
1.9× outside tolerance → ESCALATE
▲ verified $71,200 (within band)
▲ billed $134,400 (outside → flagged)
Disposition Summary — Advisory Only
| Disposition | Claims | Meaning | Amount in Question |
|---|---|---|---|
| Verified | 315 | Claim is accurate. Pay as submitted. | — |
| Adjust | 27 | Correctable inaccuracy. Recommended adjustment documented. | $182,000 |
| Hold | 3 | Additional provider documentation required before verification completes. | $19,500 |
| Escalate | 5 | Material discrepancy. Employer/TPA decides; Caliber documents and recommends. | $215,000 |
| Total | 350 | 35 flagged (Adjust / Hold / Escalate) · 315 Verified | $416,500 |
Dispositions are advisory only. Caliber never issues a denial and never directs payment. The four dispositions are Verified, Adjust, Hold, and Escalate — the employer and TPA retain full authority over every payment decision.
Findings Breakdown — by Check
| Check | Flagged | Avg. Discrepancy | Disposition | Total |
|---|---|---|---|---|
| CODEVAL — Upcoding | 10 | $5,500 | Adjust | $55,000 |
| DURVAL — Length of Stay | 5 | $16,500 | Adjust | $82,500 |
| DUPCHECK — Duplicate | 3 | $60,000 | Escalate | $180,000 |
| RATEVAL — Rate / Fee Schedule | 7 | $3,500 | Adjust | $24,500 |
| CREDVAL — Credential | 3 | $6,500 | Hold | $19,500 |
| BUNDLEVAL — Unbundling | 5 | $4,000 | Adjust | $20,000 |
| SVCVAL — Service Verification | 2 | $17,500 | Escalate | $35,000 |
| Total — 7 Checks | 35 | 10% by count | $416,500 |
Roughly 10% of reviewed claims carried at least one discrepancy; dollars in question represent about 2% of reviewed spend ($416,500 of $21.0M). Most findings are partial adjustments, not full-claim errors — duplicates (DUPCHECK) are the exception.
Key Metrics
$416,500
Prevented Overpayment
~2% of reviewed spend
$341,530
Stays with Employer
82% of every prevented dollar
10%
Claims Flagged
By count (350 reviewed)
Program Economics — Contingency
Prevented overpayment (verified, line-item)
$416,500
Caliber share (18% of prevented)
$74,970
No savings, no fee · pure contingency on verified prevented overpayment
Net to employer (82% retained)
$341,530
Prevention vs. recovery
100¢ vs ≈12¢
Every prevented dollar is documented at the line-item level and independently verifiable against claims data — not modeled, not estimated. Post-payment, retrospective recovery yields about 12¢ on the dollar (OIG recovery rate) after 12–18 months of disputes and fees; pre-payment, you keep 100¢ — you never pay the bad claim. No broker or consultant referral fee is paid into or out of this engagement — independence is the moat.
Top 5 Highest-Value Findings
Claim #A-2893 — NICU Stay (22 days)
Escalate: $63,200
DUPCHECK — Duplicate Billing
Same admission submitted by the facility and a contracted billing entity for the overlapping date range. Independently confirmed as a full duplicate against the claims extract. Escalated for employer/TPA decision — Caliber documents the duplicate and recommends withholding the second submission. NICU admission cost benchmark: ~$71,200 (regional commercial NICU per-stay range; source on file).
Billed: $134,400
Verified: $71,200
1.9× outside tolerance
Claim #A-4471 — Spinal Fusion
Escalate: $58,800
DUPCHECK — Duplicate Facility Charge
Duplicate facility charge for the same operating-room session, submitted under two place-of-service codes. Confirmed against CCI edits and the facility billing record. Escalated — the employer directs the payment decision; Caliber provides the evidence.
Billed: $187,000
Verified: $128,200
1.5× outside tolerance
Claim #A-1156 — Inpatient Psych (DURVAL)
Adjust: $16,500
DURVAL — Length-of-Stay Variance
Continued-stay days billed beyond the point supported by concurrent-review documentation. Recommended adjustment to the documented authorized length of stay. Correctable inaccuracy — Adjust disposition; recommended corrected amount documented for the TPA.
Billed: $98,500
Verified: $82,000
1.2× outside tolerance
Claim #A-5034 — Transplant Evaluation
Escalate: $17,500
SVCVAL — Service Verification
Billed services exceeded what the clinical record documents as delivered for the evaluation episode. Material discrepancy escalated for employer/TPA decision; Caliber documents the gap between billed and delivered and recommends the corrected amount.
Billed: $156,000
Verified: $138,500
1.1× outside tolerance
Claim #A-3720 — Joint Replacement
Adjust: $5,500
CODEVAL — Upcoding
Procedure coded one level above the documented complexity. Recommended recode to the supported CPT with the corresponding fee-schedule amount. Correctable — Adjust disposition; the TPA processes the corrected claim.
Billed: $112,000
Verified: $106,500
1.05× outside tolerance
Methodology
| Standard | Billing Governance Standard (BGS) v1.0 |
| Verification Checks | Seven checks applied to every claim above threshold |
| Claim Threshold | $25,000 billed amount |
| Reviewer Credentials | CPC, CCS, or RHIA — credentialed professionals |
| Dispositions | Verified · Adjust · Hold · Escalate — advisory only; Caliber never issues a denial |
| Scope Limitation | No provider contact, no member contact, no payment instruction. The employer and TPA retain full authority over every payment decision. |
| Verification Period | Representative year — 12-month governance cycle |
Independence Attestation
“This certificate was produced by an independent verification entity with no financial relationship to the third-party administrator, provider network, or claims processing system serving this population. Caliber takes no broker or consultant referral fees and pays none — no finder’s fee, no channel compensation, no percentage of PEPM.”