---
name: honest-standard-monthly-check
description: Use this skill when a practice running a Medicare between-visit program (chronic care management, remote monitoring, transitional care, APCM, behavioral health integration, and the like) wants to check each month that it is billing for real, needed, understood, and truthfully documented care, before an auditor, a payer, or a complaint does. It runs the book's Honest Standard, seven tests on a random sample of ten records, checks the three documentation drift signals (time clustering at a threshold, identical text, frozen care plans), reads the program's rules for bureaucratic and fraudulent drift, reviews the consent script and any vendor contract for the behavior they reward, lists who should stop receiving the service, and states what to fix, hold, stop billing, or take to a compliance adviser. Triggers on requests like "run our Honest Standard check," "audit our CCM notes," "are our minutes clustering at twenty," "is our consent script honest," "review this care-management vendor contract," "who should we disenroll," "prepare for a compliance review," or "how do we not become Summit."
---

# Honest Standard Monthly Check
This skill is Labor as Code™ for the integrity method in *Getting Paid
to Do the Right Thing*. Labor as Code is a
skill that encapsulates a person's knowledge, judgment, taste, and skill
in durable, inspectable, versioned form. The know-how is holding a
between-visit program to a standard stricter than eligibility, every
month, from inside the practice: eligibility tells you a service can be
billed, and the Honest Standard asks whether it should be delivered,
whether it was, and whether it helped.

The method lives in "Don't Turn Good Reimbursement Into Bad Medicine":
the honest behavior and the two drifts behind each payment rule (Table
15.1), Summit Endocrine's fourteen months, the seven tests with the
evidence to check for each (Table 15.2), Riverbend's monthly self-check,
consent as a conversation about money, the three documentation drift
signals, vendor contracts, and the four reasons to stop a service. The
monthly worksheet is "Honest Standard monthly check" in "Field
Worksheets." Read them for the argument and the cases. This skill runs
the same check on the user's own program and never treats Summit's or
Riverbend's findings as the user's.

**This is an operating discipline, not legal advice.** The book says it
plainly and so does this skill: whether a specific arrangement,
contract, or billing practice is lawful in the user's state and with
their payers is a question for a qualified healthcare attorney or
compliance adviser. The skill never says a program "is compliant," never
says a claim must or needn't be repaid, and routes every legal question
to that adviser with the evidence attached.

**Clinical calls stay with clinicians.** Whether a patient needs the
program is a clinical judgment. The skill lays out the evidence in the
record and what's missing; a clinician decides.

**The skill takes de-identified records only.** Names, dates of birth,
record numbers, addresses, and phone numbers removed, dates replaced
with day offsets, or a tool covered by the practice's business associate
agreement used under its rules. Patient-understanding calls are made by
practice staff, not by the skill.

## Before running

1. **Name the program and the month.** One check per program per month.
2. **Name who runs it.** The book's pattern is a care-management lead
   and a physician together, about thirty minutes. A small group names
   one compliance lead across sites and runs the check at every site on
   the same schedule; a large organization samples every team and
   includes clinicians among the reviewers.
3. **Pull the sample.** Ten enrolled patient-months at random, not the
   ten the team knows best. Ask the user how they randomized.
4. **Gather what sits outside the records.** Phone-system or message
   timestamps for the sampled months, the list of patients disenrolled
   this month with reasons, complaints about the program, the consent
   script in use, any vendor contract, and last month's findings.

## Step 1: Run the seven tests on the ten records

For each sampled patient-month, answer yes or no to each test, with the
evidence behind the answer and what's missing:

| Test | What it asks | Evidence to check |
| --- | --- | --- |
| Medical necessity | The patient needs this | The problem the program is managing and why it needs attention between visits |
| Real service | The work happened | Call logs, phone-system records, or message timestamps matched against documented time |
| Patient understanding | The patient knows what they agreed to and what it costs them | A short call to a few enrolled patients: what is this program, and what does it cost you? |
| True documentation | The record describes reality, not a template | Two notes side by side: could you swap the patient names without anyone noticing? |
| Right supervision | The right licensed person is responsible | Which billing practitioner is responsible, and whether that clinician has seen the care plan |
| Measured outcome | Someone checks whether it helped | One clinical measure per program, tracked for enrolled patients |
| Willingness to stop | The practice ends services that don't help | Patients disenrolled this month, and why |

1. For medical necessity, report what the record states and leave the
   judgment to the clinician. Strike any sentence in the skill's own
   output that says a patient "needs" or "doesn't need" the program.
2. For real service, compare documented minutes with the timestamps
   the user supplied. Note the direction of each difference. Documented
   time a little shorter than the phone log is the direction you want an
   error to run; documented time longer than any record of the work is a
   finding.
3. For patient understanding, the user's staff call about three of the
   ten and ask two questions: what is this program, and do you get a
   bill for it? The skill records the answers the user reports. An
   answer that names another office is a sign another practitioner may
   be billing the same service for the same month.
4. For measured outcome, count how many sampled patients have a recent
   value for the program's chosen measure. A patient with no value is a
   patient nobody can say the program helps.

## Step 2: Check the three drift signals across the sample

These are cheap, countable, and the ones a compliance reviewer looks
for:

- **Time clustering.** Real work produces a spread of times. Count the
  sampled documented times that sit within two minutes above a billing
  threshold. If the user can supply counts per time band for the last
  three months across the whole program, check the distribution, not
  just the sample. A pile just above the threshold means somebody is
  writing to it.
- **Identical text.** List any phrase repeated word for word across
  different patients' notes, beyond headings and standard labels.
- **Frozen plans.** Notes that say the care plan was reviewed when the
  plan hasn't changed in months, for patients whose conditions have.
  Also check for medication lists copied forward from last month.

If the program uses AI drafting or ambient documentation, apply the same
rule the book gives: the person who signs the note attests that it
describes what happened. A draft that says more than happened is wrong,
however well it reads.

## Step 3: Read the rules for drift

For each requirement the program checks before billing (a monthly time
threshold, consent, a care plan, device data days, a contact deadline),
write three lines: the honest behavior, the bureaucratic drift, and the
fraudulent drift. Use the book's Table 15.1 as the pattern: for a
monthly time threshold, the honest behavior is doing the work the
patient needs and recording the time it took; the bureaucratic drift is
stretching calls or calling patients who don't need a call so the month
counts; the fraudulent drift is recording twenty minutes for a
four-minute call.

For each requirement, name one early warning sign the practice can
count in its own records. Drop any sign it can't count ("staff
morale"). The bureaucratic drift is the real risk for an ordinary
practice, because it happens gradually and looks like diligence, and it
is the road to the fraud column.

Then check what staff and vendors are measured and paid on. Whatever
the practice measures its staff on, they will produce. Paying anyone
per enrollment or per billed minute is a finding on its own.

## Step 4: Check the consent script

If the user supplies the script and the list of required consent
elements from the payer's current guidance or their compliance adviser:

1. Quote the sentence that covers each required element, or mark it
   missing.
2. Check that a patient hearing it on the phone would know what the
   program is, what it will cost each month in plain dollars (after the
   practice checks secondary coverage), that only one office can provide
   it at a time, and that they can stop at any time.
3. Check that it asks whether another office already calls the patient
   every month, and that it offers time to think.
4. Flag any script that calls the program "free," promises to waive or
   cover the patient's cost, or pressures a decision on the call.
   Whether a practice can reduce or waive cost sharing is a compliance
   question, never something said on the phone.

The book's test for consent: if the patient is surprised by the first
bill, the consent didn't happen, whatever the chart says.

## Step 5: Read any vendor contract for what it rewards

If a vendor touches the patients or the claims, list every way the
vendor is paid and the behavior each payment term rewards and doesn't
reward. Then check for the book's six questions, quoting the clause or
marking it missing:

- What is the vendor paid for: enrollments, billed months, a share of
  collections, or a flat fee for a defined scope of work?
- Who owns consent: whose script, whose recording, whose sign-off?
- How does the vendor coordinate with the practice's own clinicians,
  and who stops a vendor call when the practice's nurse or educator
  already manages the patient?
- What can the practice audit, and how fast: any note, call record, or
  claim on demand?
- What happens when an audit fails: does the vendor share repayment and
  rework, or keep its fees?
- How does the practice leave: patient notification and record
  ownership?

Every claim goes out under the billing practitioner's name, whoever did
the work. Treat anything about legality as a question for the attorney,
and hand over the missing-clause list.

## Step 6: List who should stop

From the sample and the program's disenrollment list, list patients the
clinician should consider for stopping, by the book's four reasons:

- **The need resolved** (for example, controlled for months on a stable
  regimen, with calls that have become social).
- **Someone else is doing it** (another practice, a specialist, or a
  health plan's program).
- **The patient doesn't want it** (said yes to be polite, doesn't
  answer).
- **It isn't helping** (months of calls, no change in anything
  measured, and no clinical reason to expect one).

A program that disenrolls nobody for six months is telling you nobody
is looking.

## Step 7: Conclude with actions, owners, and what goes to the adviser

Close with a short statement:

- **Results by test:** passes and fails across the ten, and which tests
  repeat a failure from last month. Two months in a row with the same
  "no" means the process, not the person, needs changing; name the
  process.
- **Each "no" with a named owner and a fix before next month's claims
  go out.** Where a sampled month fails real service, true
  documentation, or right supervision, recommend holding that claim (or
  reviewing it, if it already went out) and taking it to the compliance
  adviser. The skill doesn't decide repayment.
- **The drift reading:** whether the program shows bureaucratic drift
  (time clustering, identical text, frozen plans, incentives that pay
  for the proxy), with the counted evidence.
- **Consent and contract gaps,** each with who fixes it.
- **The stop list** for the clinician to decide on.
- **A program-level call:** keep running and check again next month;
  hold new enrollment until named failures have owners; or bring the
  program to its quarterly stop, hold, or scale review early because it
  failed an Honest Standard test in a way the process can't fix.
- **Compliance review.** If the program is about to scale, or its
  staffing or payment has changed, say it needs a qualified adviser's
  review first, and assemble the packet the book recommends: the consent
  script, the written workflow, the last three months of Honest Standard
  findings, the distribution of documented times, any vendor contract,
  and the stopping rules. List the evidence the practice has and lacks
  for each of the seven tests, and the questions it can't answer yet.

Where the evidence supports two readings (a time pile at the threshold
that could be writing to the threshold or could be a program whose
standard call genuinely runs that long), present both, with the check
that would settle it (phone-log match, a wider sample). Where the sample is too small or the records
too thin to judge a test, say so and name the evidence that would
resolve it. Never round a thin sample up to a clean bill of health.

## Checks before calling the work done

- **The sample was random,** and its ten patient-months are
  de-identified.
- **Every test has a yes or no with evidence,** or "can't judge" with
  what's missing.
- **No sentence says a patient needs or doesn't need the program,** and
  none says the program is compliant.
- **Time clustering and identical text were counted,** not described.
- **Every "no" has an owner and a date before the next claims run.**
- **Legal questions are listed for the adviser,** not answered.

## What this skill does not do

It doesn't give legal, billing, coding, or compliance advice, and it
doesn't decide repayment. It doesn't decide medical necessity or
disenroll anyone; clinicians do. It doesn't call patients. It doesn't
accept identifiable records outside a tool the practice has a business
associate agreement for. It doesn't treat eligibility as the standard:
every patient Summit enrolled was eligible. And it doesn't replace the
monthly human read; software makes the sample cheap to check, and people
decide what the findings mean.