HIPAA Compliant • SOC 2 Type II Certified

Risk Intelligence for Healthcare Administrators

Claims-driven risk assessment, continuous monitoring, audit prep, investigation, and corrective action — the OIG compliance lifecycle, operationalized. Built for ACOs, health plans, medical groups, MIPS groups, and private practices carrying real performance risk.

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Secure data feeds
One Unified Platform
Risk Intelligence Dashboard with Risk Flags

The Challenge

Small Teams. Massive Surface Area. Rising Stakes.

A compliance officer is expected to own risk assessment, monitoring, audit prep, investigation, and corrective action across millions of claim lines and hundreds of providers — often with a team that fits around a conference table. Value-based care multiplies the surface: every risk-based contract, every MA member, every HCC code, every delegated entity is another obligation.

Headcount isn't the answer; regulators expect more, not less. The work needs instrumentation — systems that handle detection and documentation so your team can focus on judgment.

$6.8B
DOJ False Claims Act settlements in FY2025 — $5.7B tied to healthcare
~550
MA contracts now audited annually under CMS RADV (up from ~60)
$17B
Estimated annual Medicare Advantage overpayments CMS is now recovering

Our Approach

One Claims Feed. Full Compliance Lifecycle.

Pamastay unifies claims from CCLF, EDI 837, and direct extracts into a single compliance layer — then runs the work on top. Ongoing risk assessment, continuous monitoring for anomalies as they surface, investigation workflow for every finding, and corrective-action tracking that closes the loop. Built for the era of human insight, machine learning, and artificial intelligence.

Unified schema across CCLF, EDI, and direct feeds
Flag known CMS signals
Identify 3rd party fraud claims
Benchmark coding behavior
Provider Analytics View

How It Works

From Risk Assessment to Corrective Action

Three integrated phases that cover OIG compliance program elements 6 and 7 — the two that actually run on claims data.

1

Assess & Monitor

Claims-based risk scoring across CCLF and EDI feeds. Continuous surveillance for MUE violations, orphan DME, HCC gaps, and cost outliers — always on, not seasonal.

2

Audit & Investigate

RADV-ready audit packages, provider drill-downs, and peer benchmarking. Build defensible findings with detection logic and historical evidence attached.

3

Act & Follow Up

Track every finding through corrective action, provider education, and verification. Export for committees, boards, and regulators — closing the loop that OIG Element 7 expects.

Regulatory Intelligence

We Track What CMS and OIG Track

Our public enforcement feed mirrors CA DMHC actions and federal OIG resources — so your program knows what regulators are focused on this quarter.

Active enforcement
Kaiser Permanente — $556M MA settlement
Invalid diagnosis codes submitted to inflate Medicare Advantage payments. The largest VBC-era settlement and a direct preview of RADV priorities.
CMS scaling up
RADV moving from ~60 to ~550 audits/year
Payment Year 2020 audits began Feb 2026. Coder capacity scaling from 40 to ~2,000 with AI-assisted review. Delegated entities are in scope too.
State-level signal
169+ CA DMHC actions in 2025 YTD
State regulators are moving in parallel with OIG. Our enforcement tracker surfaces the violations, penalties, and patterns to watch.
Open the Enforcement Tracker

Ready to See What's Hiding in Your Claims Data?

Book a demo and we'll show you Pamastay with sample data—or connect your own claims feeds.

Schedule a Demo