Kisa eb927258c6 refactor: reorganize repo structure — flatten CGM-Denial-Prevention/ and Projects/ into docs/ pitch/ research/

Co-Authored-By: Claude Sonnet 4.6 <noreply@anthropic.com>

2026-05-12 05:10:00 -04:00

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Signal CGM — Segment Scoring Model v1

Explicit Criteria, Weights, and Rankings Across Three Objectives

STTIL Solutions LLC | April 2026

Scoring Architecture

Three independent rankings. Each uses different criteria, weights, and success definitions. A segment that ranks #1 for SaaS ICP may be wrong for a pilot and irrelevant for an asset sale. Treat them as separate decisions.

Model 1: Best SaaS ICP for MRR/ARR

Criterion	Weight	What it measures
Pain intensity	25%	How acutely the segment feels the CGM denial problem
Willingness / ability to pay	20%	Named budget, ROI clarity, buyer who can sign
Revenue per customer (ARR × LTV)	20%	Monthly contract × expected contract duration
Sales cycle speed	15%	Weeks from first contact to signed contract
Churn durability	10%	Still exists and values the tool in 24 months?
Reachability at scale	10%	Find and reach efficiently without large sales org

SaaS ICP Scores

Segment	Pain (25%)	Pay (20%)	ARR×LTV (20%)	Cycle (15%)	Churn (10%)	Reach (10%)	Score
Mid-size supplier (10–50 emp)	9	8	8	7	6	7	7.80
Billing company / DME RCM	8	7	7	5	8	6	6.95
Small supplier (2–8 emp)	10	5	4	6	4	8	6.40
VGM Group / MSO	5	4	7	3	9	5	5.30
DME platform vendor (NikoHealth)	3	4	8	2	9	3	4.65
State / national association	2	1	1	3	7	9	2.55
Grant-funded / QI org	3	2	2	2	4	4	2.60

Key rationale:

Mid-size supplier leads because they have pain + budget + ROI clarity at $199–$399/month
Small supplier has maximum pain (10/10) but minimum reliability — high churn risk as CB 2028 approaches
Billing company scores #2: absorbs denial labor directly; LTV longer than any individual supplier
NikoHealth scores low on SaaS — they are an asset buyer, not a subscriber

Model 2: Best Buyer for Asset Sale / Strategic Handoff

Criterion	Weight	What it measures
Distribution reach	30%	How many suppliers does this buyer already reach?
Strategic need	25%	Documented feature gap; would they build it otherwise?
Price ceiling	20%	How much would a motivated buyer plausibly pay?
Speed to close	15%	Weeks from conversation to signed term sheet
Build vs. buy calculus	10%	Is acquiring faster than building given CB 2028 window?

Asset Sale Scores

Segment	Distribution (30%)	Need (25%)	Price (20%)	Speed (15%)	B/B (10%)	Score
DME platform vendor (NikoHealth)	10	9	9	3	7	8.20
VGM Group / MSO	10	7	7	4	8	7.55
Billing company / DME RCM	7	8	6	5	7	6.75
State / national association	8	4	2	2	3	4.40
Mid-size supplier	1	5	2	4	3	2.85
Small supplier	1	4	1	3	2	2.10
Grant-funded / QI org	3	3	2	1	2	2.40

NikoHealth (#1 asset buyer) rationale:

Already serves the exact buyer profile; CGM feature gap is documented and real
API-first architecture makes integration technically trivial
CB 2028 window makes buying faster than 6–9 month internal build
Price ceiling is 3–5× current $25K–$60K ask for a motivated platform buyer

Model 3: Best Pilot Validation Partner

Criterion	Weight	What it measures
Data accessibility	25%	Structured CGM billing data with denial reason codes
Cooperation likelihood	20%	Will they actively participate and give feedback?
Signal quality	20%	Will pilot results generalize to target market?
PHI / compliance overhead	20%	BAA and data security burden
Feedback loop speed	15%	How quickly is denial rate change measurable?

Pilot Scores

Segment	Data (25%)	Coop (20%)	Signal (20%)	PHI (20%)	Speed (15%)	Score
Billing company / DME RCM	10	7	10	6	6	8.00
Mid-size supplier	8	8	9	5	8	7.60
DME platform vendor	10	4	10	7	4	7.30
Small supplier	6	9	7	5	7	6.75
VGM / MSO	3	5	4	4	3	3.80

Billing company leads pilot scoring because they have multi-supplier, multi-plan, multi-jurisdiction billing data — the fastest path to H1 validation (denials are documentation-fixable) across a meaningful sample size.

Government Enforcement Context

Finding	Source	Strategic Implication
CGM improper payment rate: 25.2% / $278.5M/yr	CMS 2024	One in four CGM dollars improperly paid
94.2% from documentation failures	CMS 2024	Not fraud — fixable workflow gaps
$1.9B total DMEPOS improper payments FY2024	OIG	CGM is highest-scrutiny category
$1.8B in payments suspended 2025	CMS Fraud Defense Ops	Enforcement is executing at scale now
CGM as explicit 2026 enforcement priority	OIG / DOJ	Legitimate suppliers get caught in sweeps
Unequal enforcement: pharmacy vs DMEPOS	CMS-2025-0242-0025	DMEPOS held to higher standard than pharmacy for same product

The dual-edge positioning: Signal CGM's audit log is not just a billing tool — it is liability documentation. A supplier who can show time-stamped pre-submission checks has a defensibility argument when the MAC issues an ADR.

NikoHealth Foothold Assessment

Verdict: Credible and growing challenger. Not the market standard.

Indicator	Assessment
Architecture	Cloud-native, API-first — genuine advantage over Brightree
Pricing	More accessible for small suppliers than Brightree ($600–$1,500+/mo)
Market position	Capturing switchers from legacy platforms; not dominant
Customer count	G2 review volume suggests low hundreds, not thousands
CGM-specific intelligence	Generic authorization alerts; no 6-month visit tracking, no MAC-jurisdiction rules, no 45-day runway logic
Competitive risk	Could close the CGM gap in 6–9 months of focused engineering

Asset sale timing window: open but not permanent. NikoHealth's API-first architecture makes acquisition or licensing integration technically trivial relative to Brightree's legacy stack.

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