Keep the person whole.
At home.
KEEP is the benefit manager built for the chronic wound. A home-care spine, an evidence formulary, and the one record claims can't see: whether the wound closed and the limb was kept.
North-star metric: limbs kept. Not dollars. The dollars follow.
A wound is not a billing line. For too many patients it is the start of a countdown.
Five years after a major diabetic-foot amputation, more than half of patients are gone6. And the people losing limbs are not chosen at random7. Chronic wounds already cost Medicare more than $28 billion a year across 8.2 million beneficiaries, roughly one in seven8. KEEP exists to bend that countdown the other way.
A market broke, got fraudulent, and came to a reckoning in the same eighteen months.
Skin-substitute spend ran away, the courts caught a billion-dollar scheme, and CMS slammed the price. Each one alone would matter. Together they open the door for a manager.
About 40x in five years
Medicare Part B skin-substitute spend went from $256M in 2019 to over $10B in 2024 while the patient count only roughly doubled1. Dollars outran people by 20 to 1.
Adjudicated, not alleged
An Arizona wound-graft scheme drew guilty pleas and 15.5- and 14-year sentences, plus $309M in civil recovery5. The money was real. So was the harm.
Dollars outran patients, 2019–2024
Medicare Part B skin-substitute spend, plotted against the patient count it was meant to track.1
CMS fixed the price. It did not fix the coverage.
The new rate caps dollars per square centimeter. It says nothing about which product, which wound, how many applications, or how large a graft. And on December 24, 2025, the seven Medicare Administrative Contractor (MAC) coverage rules that would have answered those questions were withdrawn4.
What is now capped
- Dollars per square centimeter, flat at $127.142
- Same rate in office and hospital outpatient
- Paid as an incident-to supply, not a marked-up product
What is still unguarded
- Which product, of 361 on the list
- Which wound, which indication, medical necessity
- How many applications, how large a graft. A flat per-cm² rate even rewards larger grafts
CMS capped the dollars-per-unit and walked away from medical necessity. No regulator has stepped in to fix the other side. That is the benefit manager's job.
KEEP manages the episode, not a product.
The skin substitute is the trigger, not the prize. KEEP runs the whole wound episode — from home nursing through escalation and step-down — inside one managed pathway. The formulary and the closure registry sit inside it, not beside it.
A manager that touches only the formulary manages the loud ten percent and leaves the real money — and the real outcomes — untouched. So KEEP owns one disease, vertically, all the way down: home nursing, medications, labs and the vascular gate, offloading, and the right level of care escalated up or stepped down as the wound moves. One disease. Not all of healthcare.
The wound episode, escalated up and stepped down
One managed pathway across levels of care. Ancillary services are the levers; the formulary and registry sit inside; everything is orchestrated to one number.
kept
The right care
- More home-nurse monitoring — the visit that catches infection early
- The vascular gate before any advanced product is approved
- Offloading, correct antibiotics, glycemic and nutrition support
- Escalation to vascular, surgery, or hyperbaric oxygen (HBOT) the moment the limb is threatened
The wasteful care
- Over-grafting — product applied where it cannot help
- Grafts on limbs with no blood supply to heal them
- Applications beyond evidence, larger grafts the flat rate rewards
- Wound-center utilization the patient could get safely at home
Managing the right care up and the wasteful care down is what makes lead with limb preservation, savings follow true, not a slogan. The savings are the consequence of better care, never the goal we open with.
The risk ladder
KEEP climbs from administrative fees toward a capitated wound carve-out. You can only take a capitated rate if you can move the outcome, and the registry is how KEEP proves it. The carve-out is the wound condition only — condition cost of care, never total cost.
Admin / PMPM management fee
Formulary, evidence-aligned prior auth, network access, and the wound-spend diagnostic.
Performance guarantees
Closure-rate and limb-preservation targets put fees at risk against real outcomes.
Capitated wound carve-out (CCOC)
A per-member rate for the wound population, keeping the spread it saves. Precedent that payers will capitate a young vendor: Synapse Health / UnitedHealth, DME, 2026.
Rung one starts with your own numbers. Open the wound-spend diagnostic →
Claims can't see whether a wound closed. KEEP owns the record that can.
A claim records that a graft was applied and paid for. It does not record whether the wound closed, whether the limb was kept, or whether a cheaper product would have closed it faster. Every incumbent shares that blind spot.
KEEP makes photographic, measurement-based wound documentation a network-contracting requirement — every wound, every visit. That produces the only closure-rate dataset segmented by product, provider, and wound type, owned by KEEP and reported to the payer: the record claims data can't supply.
The registry is the steerage engine. Once you can see which products and which providers actually close wounds, you point volume there, and the limb-preservation rate is what moves first. It is also what lets KEEP bear risk at all: you can only take a capitated rate if you can move the outcome, and you can only prove you moved it if you own the measurement.
And it is the defense. A UM rule copies in a quarter. A longitudinal closure registry, plus the home-care spine underneath it, takes years to build.
- The closure registry — the record, the risk-enabler
- Tele-wound MD/NP supervision — the clinical brain over every case
- The evidence formulary — which products earn their place
- The steerage engine — volume goes to what closes
- The hands-on home visits, through credentialed home-wound-care providers. KEEP does not employ a field workforce.
- A paperwork-only manager can't move outcomes, so it is stuck at thin fees. An own-and-operate provider is labor-bound. The hybrid is the structure built to reach a capitated carve-out.
Be the brain and the scoreboard; rent the hands.
What KEEP reports back is limbs kept.
Not dollars saved. A limb preserved. A wound closed. A person kept whole, at home.
The metric is limb-preservation rate, supported by closure rate, and only then by cost. Run the toggle: when a wound benefit is managed, the outcomes move first. The savings are the quiet consequence, and they come last.
A wound population, unmanaged vs. managed
Every payer. We start where the dollars are most exposed.
The genuinely unmanaged spend sits in commercial and Medicaid, where there is no CMS rate to cap it and no public dataset even sizing it. Medicare Advantage already manages this. We meet each payer where it actually stands.
Commercial
Same clinical wound burden, no CMS rate to cap it, weak medical policy in many plans. The most exposed dollars, and the clearest first meeting.
Medicaid MCOs
FFS segments and weak-policy states carry the same risk with no public number sizing it. A regional MCO without internal wound capability is the wedge buyer.
Medicare Advantage
Already self-manages this through prior auth: only ~7% of FFS skin-sub spend despite over half the lives9. Pitched as managed services, the home spine, and the registry. Not a rescue.
Medicare FFS
Got the price fix but still carries coverage-side risk: larger grafts, more applications. A managed pathway still has a job through the coverage gap.
The whole model, walked end to end. See the walkthrough →
THE OPERATOR
Joe Nalley
Founder, KEEP
Built by someone who has carried patients and built the businesses around them.
Joe Nalley built KEEP from inside the machinery of payer growth. Today he is Staff Vice President of Carelon Growth (Elevance Health), at national scale.
He founded and sold ClearBill, which returned $9.2M to payers in its first six months. He built and exited GetWell, a 13-location behavioral-health and substance-use provider that served more than 30,000 patients.
Across a career in care delivery and payer growth, he has been responsible for more than 200,000 lifetime patients served. KEEP is the benefit manager that work has been pointing toward.
The four questions payers ask first.
Fair questions, all four. Here are the straight answers.
- Objection · 01"Why not just write a UM policy?"
- A UM policy polices the graft; it cannot see whether the wound closed. It also copies in a quarter, so it confers no lasting edge. The closure registry and the home-care spine are what a policy can't replicate, and they are what actually keep limbs.
- Objection · 02"Isn't this a denial machine?"
- No. The model adds care: more home-nurse visits, tele-wound supervision, the vascular gate, photographic documentation at every visit. What it removes is waste, mostly over-grafting, and the number KEEP reports back is limbs kept, not claims denied.
- Objection · 03"Why won't TurningPoint or Optum do this?"
- They might try; TurningPoint already lists wound care across 42M lives. But horizontal UM has not shown the two things that move the outcome: a home-delivery spine and a closure registry. A rule book scales fast. A record of what actually closes wounds does not.
- Objection · 04"Why would we capitate a young vendor?"
- You wouldn't on day one, and KEEP doesn't ask you to. The ladder starts at an admin fee, puts fees at risk against closure and limb-preservation targets second, and treats capitation as the destination, not the ask. The precedent that payers will capitate a young vendor for a carve-out is recent: Synapse Health and UnitedHealth, DME, 2026.
Book the wound-spend diagnostic.
One condition, the diabetic foot ulcer. One artifact: your own 40x chart, built from public and plan-shareable data, so your plan sees its own exposure. No network required to produce it.
We open with limb preservation. We close with limbs kept. The savings are real, and they come last.