Care Intelligence Platform for healthcare practices

What payers are doing right now. How it affects your revenue. What to do about it.

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Upstream is a Care Intelligence Platform. It detects payer behavior shifts (denial spikes, adjudication policy changes, payment slowdowns) before traditional reporting catches them. Operators across eight healthcare specialties use Upstream to act before the damage lands.

It is not a clearinghouse. Upstream sits on top of your existing billing stack as a force multiplier. We do not bill payers. We do not bill patients. We do not replace your billing team. We tell them what to work on and when.

Pioneer beta is open. $49 per month, locked for life. First actionable payer pattern in 30 days or your money back.

Claim a Pioneer seat · Free claim audit

Your billing team learns about a denial spike when this month's report lands. By then it has already cost you the quarter.

Upstream is the early warning system. We monitor payer adjudication patterns and surface shifts the first time they appear, not the thirtieth. Your team gets an actionable alert in their queue with the specific payer, the specific code, and the specific fix. Before the wave hits.

Works across ABA, SNF, PT/OT, dental, dialysis, imaging, home health, and behavioral health. The detection engine is the same across specialties. The verticals add the workflow.

1. Connect. Claims data, 835 remittance, authorization data, EHR webhooks. APIs, CSV uploads, or pre-built connectors.
2. Detect. DriftWatch (statistical denial rate detection), DenialScope (dollar weighted impact), DelayGuard (payment timing deterioration), and specialty specific checks run continuously.
3. Prioritize. Issues route by confidence tier and dollar weighted impact. The highest impact, highest confidence work surfaces first.
4. Act. One click appeal generation. Auto submit for low risk fixes. Escalate high impact decisions to operators with the document trail attached.

Setup is 12 minutes. Pioneer beta target: first actionable payer pattern in 30 days or your money back.

Upstream maintains active integrations with the following public reference systems. These are the truth sources we synchronize against for codes, rates, and policy data.

How Upstream compares to other categories of healthcare revenue tooling. Upstream is in a different lane than clearinghouses or legacy enterprise RCM. Most operators run Upstream alongside their existing stack.

We built Upstream after sitting in too many billing meetings where the team learned about a denial spike from last month's report. By then it was already a quarter of revenue gone.

The early warning systems already existed in finance, retail, and ad tech. Healthcare revenue cycle had nothing comparable. Vendors guarded their methodology. Operators flew blind.

So we built the early warning system we wished existed. Then we open sourced the methodology so the broader RCM community can audit it, build on it, and contribute back.

This is a serious vendor for a serious problem. It is also, transparently, a beta. Founding operators get pricing locked for life because their data shapes what the network catches next.

5 founding operator seats. 0 claimed. Closing when claimed.

Founding seat unlocks:

• Pioneer pricing at $49 per month, locked for life across all future tiers
• Direct input into the detection roadmap
• Co-authored case study credit when your numbers improve
• Quarterly 1:1 with the founder
• First access to new specialty packs as they ship

This is not a discount tier. The 6th operator pays Starter pricing. The 100th operator pays whatever the market sets. Founding seats compound forever.

Claim a Founding 5 seat · Free claim audit first

Upstream is a working production system, not a slide deck. Numbers below are pulled from the actual codebase, not aspirational marketing.

Refreshed monthly. Last refresh: 2026-04-25.

Real alert format. Synthetic example for illustration only. Numbers are not from any specific operator.

Alert: UnitedHealthcare adjudication shift detected

Severity: HIGH Detected: 2026-04-15 at 02:14 UTC Scope: Network-wide pattern

What we saw UnitedHealthcare adjudication of CPT 97155 paired with diagnosis F84.0 shifted from a 8.2 percent denial baseline (13 week window) to 31.4 percent denial in the last 7 days. Chi-square p less than 0.001. Pattern detected on 835 remittance from multiple operators across 3 states on the same day.

Affected work in your account 23 in-flight authorizations match the new pattern.

Recommended action Review the 23 flagged authorizations in your Action Queue. Document the medical necessity rationale per the new criteria pattern (template attached). Submit revised authorizations within 14 days to avoid timely-filing risk.

Source 835 remittance pattern detection across the operator network. Chi-square statistical significance plus dollar weighted impact threshold.

This is what your billing team would see in their queue the morning a payer behavior shift hits. Not a monthly summary. Not a quarterly board slide. The actionable alert with the specific work to do.

The core platform stays private. Three tools are openly available.

What is Upstream? A Care Intelligence Platform that detects payer behavior shifts (denial spikes, adjudication policy changes, payment slowdowns) before traditional reporting catches them. Built for healthcare practices in ABA, SNF, PT/OT, dental, dialysis, imaging, home health, and behavioral health.

Who is Upstream for? Solo practitioners, billing managers, clinical operations leads, and care delivery teams at practices with 1 to 25 locations. Multi location groups and outsourced billing companies use the RCM Intelligence Command tier.

Is Upstream a clearinghouse? No. Upstream sits on top of your existing billing stack as a force multiplier. We do not bill payers. We do not bill patients. We do not replace your billing team. We tell them what to work on and when.

Is Upstream HIPAA compliant? Yes. PHI is encrypted at rest using Fernet (AES-128-CBC plus HMAC-SHA256). All claims data lives within a customer scoped tenant boundary. Network signals are derived from anonymized aggregations. Full BAA on every paid plan. SOC 2 Type II in progress.

How fast does Upstream pay back? Pioneer beta target. First actionable payer pattern within 30 days or your money back. Setup is 12 minutes.

Does Upstream work with my EHR or billing system? Upstream connects via APIs, CSV uploads, EHR webhooks, or 835 remittance ingestion. Pre built connectors are available for Epic (FHIR R4), athenahealth, and Cerner. Open Dental, Dentrix, and Eaglesoft connectors are on the roadmap.

What does Upstream cost? Pioneer beta access starts at $49 per month, locked for life. Production tiers run from $149 per month (Starter) to $1,299 per month (Enterprise). RCM Intelligence Command is $1,999 to $4,999 per month for multi location groups and outsourced billing companies. Add-on packs cover voice agents, contract leakage simulation, compliance tooling, and revenue recovery. Full pricing at upstream.cx/pricing.

Is there a free tier? The Upstream MCP server has a free tier with 500 API calls per month and no credit card. Free tools include the Plan Denial Heatmap and the Prior Auth Sandbox. The full platform requires a paid tier (Pioneer $49 per month or higher).

How does Upstream detect payer behavior shifts? Three statistical engines run continuously. DriftWatch uses chi-square tests on denial rates with 13 week baselines and 7 day current windows. DenialScope tracks dollar weighted denial spikes greater than $50K weekly. DelayGuard monitors median payment time on a 4 week rolling window. Detection methodology is open at upstream-community.

What is the network signal? When the same denial pattern appears across multiple operator practices on the same day, that is a network signal. One practice sees a normal denial. The network sees the pattern. Upstream surfaces the pattern to every operator before it propagates further.

How does Upstream compare to Adonis or Waystar? Different lane. Adonis orchestrates billing team work. Waystar is a clearinghouse plus revenue cycle management platform. Upstream watches what payers actually do to your claims and tells you 30 to 60 days before it costs you. Most operators run Upstream alongside one or both of those tools.

Is Upstream open source? The core platform is private. Three open tools are listed above. The methodology behind the detection engines is documented in upstream-community using public CMS data only.

What happens to my data? Your claims data lives in your customer scoped tenant boundary. PHI is encrypted at rest. Aggregated, anonymized signals contribute to the network detection engine. You can export your data at any time. Full data destruction available on plan cancellation per the BAA.

Can I try Upstream without a sales call? Yes. The Pioneer beta self serve at $49 per month. The free claim audit accepts a single claim file and returns denial pattern analysis without a credit card.

What guarantees do you offer? First actionable payer pattern within 30 days or your money back. We guarantee detection engine uptime of 99.9 percent on the Professional tier and above. We do not guarantee specific dollar recovery (your number depends on your volume).

Where can I learn more about the methodology? upstream-community documents the statistical and ML approach with public CMS data. The Upstream blog publishes monthly deep dives. The Upstream newsletter covers payer behavior shifts and regulatory updates.

Network signal. A denial or payment pattern detected across multiple operator practices simultaneously. Aggregated, anonymized, statistically validated.

Payer behavioral fingerprint. A composite scoring of a payer using denial rate trends, payment velocity, adjudication pattern shifts, and policy change history.

Drift detection. Statistical detection of when a payer changes their denial behavior versus a baseline window. Upstream uses chi-square plus Kolmogorov-Smirnov tests.

Payer cluster. A behavioral classification (Aggressive Denier, Slow Payer, Prompt Payer, Underpayer) derived from K-means clustering on five behavioral features.

Pre-submission risk score. A 0 to 100 score assigned to a claim before submission, weighted across denial history (40 percent), modifier risk (20 percent), denial streak (20 percent), Dx-CPT match (10 percent), and authorization presence (10 percent).

Action queue. The prioritized list of issues for billing team review, sorted by dollar weighted impact and confidence tier.

Confidence tier. A three level classification of automated actions. Tier 1 auto-executes high confidence low impact tasks. Tier 2 queues for review. Tier 3 escalates to operator decision.

RCM Intelligence Command. The Upstream tier for multi location groups and outsourced billing companies. Bundles Care Intelligence, Payer Intelligence, Denial Management, and Prior Authorization Intelligence. $1,999 to $4,999 per month.

Free monthly newsletter covering payer behavior shifts, regulatory updates, and the patterns we are catching this week. No sales pitch.

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2026-04-25 by the Upstream Intelligence team. Questions: hello@upstream.cx