skills/cim-teardown/references/overlay-healthcare.md

# Overlay: Healthcare

Use for provider, clinic, facility, care-services, diagnostics, behavioral health, or other healthcare assets where reimbursement, census or visits, staffing, and compliance drive value.

## Table of contents
1. Decision lens
2. Driver tree
3. Mandatory denominators
4. Typical gating items
5. Kill criteria examples
6. Evidence asks
7. Owner mapping
8. External triangulation when thin
9. Red flags

## Decision lens
- Are volumes and reimbursement rates real and collectible?
- Is labor availability or clinician productivity the real bottleneck?
- Are licensure, credentialing, billing, or compliance issues hiding downside?
- Does payor mix support the implied earnings level?

## Driver tree
Default equation:

`visits/census/procedures x net reimbursement per unit - direct labor - clinical supplies - occupancy - compliance burden`

## Mandatory denominators
- visits, procedures, census, occupancy, or covered lives
- payor mix and reimbursement per unit
- denials, write-offs, and cash collections
- clinician productivity and utilization
- staffing hours, agency usage, and overtime
- referral sources and concentration when material
- licensure, credentialing, and accreditation status
- compliance events, audits, and reimbursement recoupments

## Typical gating items
- EBITDA depends on reimbursement assumptions that are not supported by collections.
- Staffing economics rely on unsustainably low agency use or unusually high clinician utilization.
- Payor or referral concentration creates material risk.
- Compliance, licensure, or billing issues could impair revenue or create recoupments.

## Kill criteria examples
- `hard pass`: collections or reimbursement quality is structurally weaker than represented.
- `price reset`: normalized labor burden materially reduces earnings.
- `pause`: licensure, compliance, or audit risk is unresolved.

## Evidence asks
- billing and collections export by payor and service line
- denials and write-off reports
- clinician schedule and productivity reports
- payroll, agency staffing, and overtime summaries
- census or visit logs
- accreditation, licensure, and compliance reports
- material audit findings and repayment history

## Owner mapping
- administrator or regional operator
- revenue cycle lead
- CFO or controller
- compliance or quality lead
- medical director or clinical lead

## External triangulation when thin
- licensure and sanctions databases
- CMS or other regulator resources where relevant
- local demographic and referral context
- facility and permit records when site condition matters

## Red flags
- Revenue is presented on billed rates rather than realized collections.
- Labor assumes low agency usage despite known staffing tightness.
- Payor mix is shown without denial or collection performance.
- Compliance posture is described qualitatively without documentation.