High-cost categories run on autopilot between authorization and outcome. No one in the payment chain independently checks whether the therapy should still be running, whether the bill was right, or whether the outcome was preventable.
65,234 patients studied · $9.2M returned to payers in its first six months · Published in Pharmacy Times
13 locations built · 2 companies exited · Both chairs, same table
Between authorization and outcome, nobody's paid to check.
A therapy starts. Nothing in the standard stack checks whether it should still be running eighteen months later. A TPA processes the claim. No independent party verifies it before payment. A navigator routes the member. No fee is forfeited when the outcome fails. It's true wherever the dollar is authorized and then unwatched — and sharpest in self-funded plans, where the payer and the loser are the same entity.
Seven products. Each one stands in a gap nobody else will.
Employer healthcare costs rising 9–10% for the third consecutive year (KFF 2025). The response has been more point solutions, not fewer gaps. These are not point solutions. They are governance standards that work inside your existing stack — no facility ownership, no network fee, no downstream interest. Fee at risk against the outcome.
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Joe Nalley
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The Architecture
Seven products. Four tools. One structural argument.
Each product stands in a gap nobody else will. Independent, advisory-only, fee at risk. The tools are free — published standards and diagnostics that hold the products honest.
Products
Cadence
Specialty Rx continuation governance
Caliber
Pre-payment claims verification
Curated
Behavioral health navigation + readmission warranty
Parity engine — free on sample data; white-label for plans
Every product carries a published methodology and is built to prove itself on your own claims data.
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Joe Nalley
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Cadence · Specialty Rx Governance
29.1%
of specialty patients continuing therapy that warrants reassessment. Nearly one in three.
29.1% is the flag rate across the 30,734-patient NIH All of Us validation subset — the federal-data anchor inside the 65,234-patient evidence base.
65,234 patients · 3 locked cohorts · NIH All of Us validation $14.3M first-cycle gross savings · Published in Pharmacy Times, April 2026
Prior auth decides whether a therapy starts. Nothing in the standard stack checks whether it should still be running eighteen months later. Cadence is a governance standard — eight sections, seven reassessment triggers — that audits continuation appropriateness across biologics, specialty injectables, and high-cost oral therapies.
The prescription refills and the spend accrues. Nobody reassesses.
For your stop-loss renewal: identifies continuation waste before it inflates your loss run. The governance artifact documents what your plan did about it.
$9.2 million returned to payers. In the first six months of full deployment.
ClearBill — the engine Caliber is built on.
4–6%
Expected discrepancy rate on claims above $25K
OIG / AHLA / MGMA
7
Checks in the Billing Governance Standard. CODEVAL through BUNDLEVAL.
BGS v1.0 · Pre-payment
100¢
A dollar caught before payment never needs recovering. Post-payment recovers 12¢.
12¢ figure · OIG 2023
Claims above $25K pass through the TPA without independent verification. Caliber runs a seven-check audit during the hold window, before the money leaves. Advisory-only. Issues a Billing Governance Certificate. Never denies a claim. Independent of the network being audited — and no broker or consultant referral fee is paid or taken, so no channel compensation can bias a verification.
Your carrier reimburses verified claims, not unverified ones. Pre-payment verification prevents overpayment before it hits your spec.
Catch it before the money leaves, or chase twelve cents on the dollar.
Post-payment recovery returns ~12¢ per dollar of improper payment · OIG 2023. A dollar caught before it leaves never needs recovering.
Once a claim is paid, the money is already gone. Pay-and-chase recovers about twelve cents of every dollar overpaid. The other eighty-eight cents stays out the door — written off, fought over, or never found.
A dollar verified before it leaves is worth eight of the same dollar chased after.
Caliber runs its seven-check audit during the TPA hold window, before payment clears. Same dollar, caught at the only point recovery is whole. That timing is the entire argument.
One navigator. The whole episode. Fee at risk against the outcome.
Curated · Behavioral Health
One navigator per member. Every BH episode. For as long as they're covered.
Quality-scored provider database across 13 clinical areas. Episode-chain continuity. 30-day readmission warranty on SUD residential and acute psych — fee forfeited on a miss.
30K+
BH patients managed across 13 locations (2012–2025)
Claims-integrated risk identification. A warranty held on Waybright's own books.
Convener model. When a readmission Waybright should have caught slips through, Waybright pays the cost of it from its own reserves, held at 1.75× expected loss. Facility-level quality data in the consumer's hands.
$376,003
modeled savings, 10K-employee plan 85.6% effective steerable fraction
Remote Medication Delivery — wearable concept IP across 4 emergency conditions. Pre-prototype.
NICU shock claims ($200K–$500K) move your spec. Maternity steering reduces them. Readmission warranties offset specific-stop-loss exposure directly.
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Joe Nalley
08
How It Works
Your data. Credentialed reviewers. Documented findings. Nothing compelled.
Step 1
You send a claims extract
Standard flat file. De-identified or under BAA. We configure the triggers. No platform install. No integration. No IT involvement.
Step 2
Credentialed reviewers do the work
PharmD, MD, and clinical specialists with therapeutic expertise. Contracted panel, external to your plan. Minimum two independent reviewers per cycle for inter-rater reliability. Every determination is human, not algorithmic.
Step 3
You hold the artifact
Documented governance record with outcome distribution, influence rates, and the full audit trail. Yours to keep. Present to your board, your stop-loss carrier, or your consultant. We compel nothing.
Data security
BAA executed before any data transfer. HIPAA-compliant infrastructure. SOC 2 pathway in progress. All data encrypted at rest and in transit.
Advisory-only. No duty to act.
External reviewers, no denial authority, no utilization management action triggered. Your team decides what to do with the findings through existing channels.
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Joe Nalley
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Track Record
The work is the resume.
Built a health system from zero — behavioral health, SUD, MAT, primary care, surgical center, community hospital. Thirteen locations. Thirty thousand patients. Ran it through acquisition. Stayed as CEO through the transition.
Built a billing verification platform. Sold it. $9.2 million returned to payers in its first six months of full deployment.
Published in Pharmacy Times. 65,234 patients across NIH-validated cohorts. 29.1% flag rate across 30,734 patients in the federal dataset.
Today: Staff Vice President of Carelon Growth (Elevance Health) — six specialty clinical risk books across $50B+ in spend: MSK, Oncology, CHF, Maternity, Autoimmune, and Dementia. The books are where every gap in this portfolio became visible.
M.S. Applied Behavior Analysis, Northeastern · 30,000+ BH patients across 13 locations (2012–2025) · 80%+ residential completion across 3,400+ admissions · joe-nalley.com
Seven products and four tools. Every site, every pricing model, every clinical standard, every line of code. Sole contributor.
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Joe Nalley
10
I run 90-day pilots. On your claims data. You keep the findings.
Every engagement starts the same way: your claims data, your baseline, your measurement. I build the scorecard before the pilot starts. Metrics are agreed, not discovered after the fact. At day 30, 60, and 90, you see what moved and what did not.
No platform install. No integration requirement. No multi-year lock-in. If the numbers do not move, you walk away with the data and the analysis. The 90 days were worth it either way.
The 90-day pilot is how these products earn their first performance record on your data. You are not buying a platform. You are hiring a governed review of your claims, run by someone who has done it tens of thousands of times.
Skin in the game from day one.
Fee-at-risk where applicable. Gain-share earned in year two, not assumed in year one.
Subscription pricing. No setup fees.
Cadence
$2–6
PMPM
Caliber
$2–5
PEPM
Curated
$4–7
PEPM
Waybright
$8 / $6 / $4.50
PEPM
Waybright is tiered. Two or more products: portfolio discount. Compass, Covenant, and FORGE are free. Equipoise runs free on sample data; white-label priced separately.
Independence is structural.
No downstream interest in volume. No provider network ownership. No PBM relationship. Findings route to your team.
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Tell me your top cost category. I'll build the pilot around your claims data.
I take two new pilot engagements per quarter. The methodology is published. The findings are yours. The risk is mine.
