There’s a kind of overbilling no audit will ever catch. Our industry calls it the gray zone.
Not fraud. The equipment shipped, the patient is real. Not quite a waste either. It’s an upgrade the patient didn’t need, but the billing code allowed. The rental extended because the rules permit it, not because the patient benefits. Billing what’s technically defensible instead of what’s clinically right.
Regulators call it abuse. And here’s the uncomfortable truth: you cannot audit a gray zone. That’s what makes it gray. Every new rule written to close it creates a new edge to bill against plus a new pile of paperwork for everyone who wasn’t abusing anything. Rules police the black and white. They have never once policed judgment.
Only two forces work in the gray zone: incentives and character.
Fee-for-service sets both against the patient. When revenue rewards the maximum billable interpretation, doing the right thing is a cost. And a supplier who runs on character alone gets slowly outcompeted by one who doesn’t. That’s not a moral failure of our people. It’s a design failure of our payment.
Flip the incentive, and the characters it can afford to show up. When revenue comes from patient results, the maximum-billable reading stops being profitable and the clinically right reading becomes the business model. The gray zone doesn’t get policed. It gets repriced.
That’s the bet behind Value Based Care at Eastern MedTech: we earn more when our patient’s do better. We earn less when they don’t.
So, a question for my fellow operators: if your revenue depended on your patient’s results instead of your shipment volume, what would the gray zone even be worth to you?
