11 KiB
Signal CGM — Re-Scored Composite Model v2
Asset Sale Primary (50%) · Pilot Secondary (30%) · SaaS Tertiary (20%)
MA + Medicaid First Proof-of-Concept Payer Scope
STTIL Solutions LLC | April 2026
Priority Weights
| Objective | Weight | Rationale |
|---|---|---|
| Asset sale / strategic handoff | 50% | Fastest path to capital realization |
| Pilot validation | 30% | Evidence from pilot raises asset sale price |
| SaaS ICP potential | 20% | Informs asset buyer's deployment ROI |
Scoring Assumption Audit
Asset Sale — Why These Weights
Distribution reach (30%): An asset sale to a platform touching 500+ suppliers is worth orders of magnitude more than one touching one. This is the dominant criterion because it determines the multiplier on the asset's downstream value.
Strategic need (25%): Pull motion (buyer has documented gap) is more reliable than push motion (we convince buyer they need it). NikoHealth's CGM intelligence gap is documented and real. Billing companies' MA plan-rule complexity is felt daily.
Price ceiling (20%): Current $25K–$60K is priced for a direct supplier buyer. A platform vendor or MSO can justify 3–5× that. Weight at 20% because price ceiling is contingent on strategic need — no need, no premium.
Speed to close (15%): Closing faster is better but not at the expense of deal size. Pursue fast-close candidates in parallel with long-cycle targets.
Build vs. buy (10%): Modifier on other criteria. Accelerates a deal that already has strategic need; doesn't create one where those are absent.
Pilot — Why These Weights
Data accessibility (25%): Pilot must generate measurable denial rate change. Requires structured CGM billing data with denial reason codes — not spreadsheets.
Cooperation likelihood (20%): Active partner engagement multiplies data access value. Poor data + high cooperation still generates useful qualitative signal.
Signal quality (20%): Pilot must generalize to the asset buyer's customer base. Single Florida supplier = anecdote. Billing company across 3 MACs = evidence.
PHI/compliance overhead (20%): High-overhead pilot = delayed pilot. Given CB 2028 window, compliance friction is a real timeline risk.
Feedback loop speed (15%): A 30–60 day feedback cycle is acceptable; 6 months is not viable given the urgency window.
Individual Segment Scores — MA + Medicaid Scope Applied
NikoHealth-Type Platform Vendor
Asset Sale Sub-Score:
| Criterion | Wt | Score | Note |
|---|---|---|---|
| Distribution reach | 30% | 10 | Serves exact buyer profile across hundreds of suppliers |
| Strategic need | 25% | 10 (+1) | MA+Medicaid scope widens the gap — no platform has plan-specific rules |
| Price ceiling | 20% | 9 | MA module = 3–5× current ask to a motivated platform buyer |
| Speed to close | 15% | 3 | Enterprise procurement: 4–8 months minimum |
| Build vs. buy | 10% | 8 (+1) | MA plan-rule maintenance is ongoing data work, not a sprint |
| Sub-score: 8.55 |
Pilot Sub-Score:
| Criterion | Wt | Score | Note |
|---|---|---|---|
| Data accessibility | 25% | 10 | Best dataset: all supplier clients across all payers |
| Cooperation likelihood | 20% | 3 (−1) | Exposing own platform gap is sensitive under MA scope |
| Signal quality | 20% | 10 | Multi-supplier, multi-plan, multi-jurisdiction |
| PHI overhead | 20% | 7 | HIPAA infrastructure exists |
| Feedback speed | 15% | 4 | Enterprise review before data access |
| Sub-score: 7.10 |
SaaS ICP Score: 4.65 NikoHealth Composite: (8.55×0.50) + (7.10×0.30) + (4.65×0.20) = 7.34
Billing Company / DME RCM Outsourcer
Asset Sale Sub-Score:
| Criterion | Wt | Score | Note |
|---|---|---|---|
| Distribution reach | 30% | 7 | Serves 10–50 DMEPOS clients per firm |
| Strategic need | 25% | 9 (+1) | MA plan-specific PA rules are their most expensive unsolved problem |
| Price ceiling | 20% | 7 (+1) | $40K–$80K justified across 20+ clients under MA scope |
| Speed to close | 15% | 5 | Owner/managing partner: 60–90 day decision cycle |
| Build vs. buy | 10% | 7 | Not a tech company; will buy |
| Sub-score: 7.20 |
Pilot Sub-Score:
| Criterion | Wt | Score | Note |
|---|---|---|---|
| Data accessibility | 25% | 10 | MA + Medicaid billing data across all clients — defines the advantage |
| Cooperation likelihood | 20% | 8 (+1) | MA complexity is their daily pain; highly motivated under this payer scope |
| Signal quality | 20% | 10 | Multi-supplier, multi-plan data |
| PHI overhead | 20% | 6 | HIPAA infrastructure exists; BAA manageable |
| Feedback speed | 15% | 6 | Fast initiation; first MA cycle data in 30 days |
| Sub-score: 8.20 |
SaaS ICP Score: 7.75 (+0.80 under MA scope — tool becomes a revenue line) Billing Company Composite: (7.20×0.50) + (8.20×0.30) + (7.75×0.20) = 7.61
VGM Group / MSO
Asset Sale Sub-Score:
| Criterion | Wt | Score | Note |
|---|---|---|---|
| Distribution reach | 30% | 10 | Thousands of small-to-mid DMEPOS suppliers nationally |
| Strategic need | 25% | 6 (−1) | MA/Medicaid are plan-specific problems outside VGM's policy leverage |
| Price ceiling | 20% | 7 | $75K–$150K justified as member benefit |
| Speed to close | 15% | 3 | 6–12 month committee procurement |
| Build vs. buy | 10% | 8 | VGM endorses/buys tools, does not build |
| Sub-score: 7.15 |
Pilot Sub-Score:
| Criterion | Wt | Score | Note |
|---|---|---|---|
| Data accessibility | 25% | 3 | No supplier billing data; must recruit members |
| Cooperation likelihood | 20% | 5 | Conceptual support; cannot drive participation |
| Signal quality | 20% | 3 (−1) | Member base skews rural/small; less MA density |
| PHI overhead | 20% | 4 | VGM as intermediary adds complexity layer |
| Feedback speed | 15% | 3 | Slow: member recruitment + separate BAAs |
| Sub-score: 3.60 |
SaaS ICP Score: 5.30 VGM Composite: (7.15×0.50) + (3.60×0.30) + (5.30×0.20) = 5.72
Mid-Size Independent Supplier
Asset Sale Sub-Score:
| Criterion | Wt | Score | Note |
|---|---|---|---|
| Distribution reach | 30% | 1 | Single supplier; no scale |
| Strategic need | 25% | 6 (+1) | MA scope raises personal pain — daily multi-plan complexity |
| Price ceiling | 20% | 3 (+1) | MA ROI strengthens argument; still marginal for asset sale |
| Speed to close | 15% | 4 | Owner decision: 2–8 weeks if motivated |
| Build vs. buy | 10% | 3 | Cannot build; would subscribe not buy |
| Sub-score: 3.30 |
Pilot Sub-Score:
| Criterion | Wt | Score | Note |
|---|---|---|---|
| Data accessibility | 25% | 7 | Structured in Brightree/NikoHealth; needs 50+ MA patients for signal |
| Cooperation likelihood | 20% | 8 | Billing manager engages daily; highly motivated |
| Signal quality | 20% | 7 (−2) | Thin MA mix reduces cross-plan generalizability |
| PHI overhead | 20% | 5 | BAA: standard, manageable |
| Feedback speed | 15% | 8 | Monthly MA billing cycle; fast iteration |
| Sub-score: 6.95 |
SaaS ICP Score: 8.10 (+0.30 — MA complexity is their most expensive unsolved problem) Mid-Size Supplier Composite: (3.30×0.50) + (6.95×0.30) + (8.10×0.20) = 5.36
Composite Ranking Summary (Base + MA/Medicaid Adjusted)
| Rank | Segment | Base Composite | MA+Med Adj | Final Score |
|---|---|---|---|---|
| #1 | Billing company / DME RCM | 7.17 | +0.44 | 7.61 |
| #2 | NikoHealth-type platform | 7.22 | +0.12 | 7.34 |
| #3 | VGM Group / MSO | 5.98 | −0.26 | 5.72 |
| #4 | Mid-size independent supplier | 5.27 | +0.09 | 5.36 |
The Sequencing Logic
The #1 and #2 positions are 0.27 points apart. This is not a clear winner — it is a parallel tracks signal:
-
Pilot with billing company first. 60 days. Generates denial rate reduction data from real MA + Medicaid billing. Low cost.
-
Use that evidence to close NikoHealth. The pilot data makes the NikoHealth asset sale conversation 3× easier and likely 2× more valuable in price negotiation.
These tracks are mutually reinforcing, not competing.
VGM is the correct follow-on distribution deal after the NikoHealth asset sale or billing company deployment — not the primary target during MA + Medicaid proof-of-concept.
MA + Medicaid: The Payer Complexity That Changes Everything
FFS Medicare: One ruleset per MAC jurisdiction (4 MACs nationally)
Medicare Advantage: 800+ plans, each with plan-specific PA rules
layered on top of CMS Part B baseline
Medicaid: 50 state rulesets, often MCO-layered within each state
TRAP: Several states have moved CGM coverage to pharmacy-only
(NY May 2024; others following) — verify before piloting
Why this matters for NikoHealth: Maintaining current MA plan-specific PA rules across 800+ plans is ongoing data work, not engineering. A supplier tool that owns this database has a moat that is expensive to replicate.
Why this matters for billing companies: They are already maintaining these rules manually in someone's spreadsheet. The pain is personal and daily.
Key Denial Quantification
| Metric | Value | Source |
|---|---|---|
| CGM improper payment rate | 25.2% | CMS 2024 |
| Projected annual improper payments | $278.5M | CMS 2024 |
| Documentation failure share | 94.2% | CMS 2024 |
| No documentation at all | 67.6% | CMS 2024 |
| Insufficient documentation | 26.6% | CMS 2024 |
| MA DMEPOS appeal success (L2) | 63.9% | KFF 2024 |
| MA PA denial rate | 7.7% | KFF 2024 |
| Write-off rate on denied claims | ~63% | Derived from appeal ladder economics |
| Net revenue loss after appeals | ~20% of gross CGM billing | Derived |