Reimbursement Is Not a Moat

A few times a month we see a pitch deck slide that reads something like: "We are uniquely positioned because we own the reimbursement workflow for 99453, 99454, 99457, 99458." The implication is that billing infrastructure is a defensible position.

It is not. It is a starting line.

The strongest version of this argument has some truth to it. Companies that figured out RPM and CCM billing in 2018–2020 had a real edge. Clean documentation, audit trails, provider-facing workflows, time-tracking against the codes — all of that took serious work to get right, and the early movers benefited from it.

That edge is gone. The codes are public. Billing partners are commodity. Any credible competitor has the same coding stack and a similar margin profile. Give a competent clinical operations lead six months of focus and they will replicate the back office.

What this means in practice

Codes are not a story for the next round. Investors who understand the space have seen this slide fifty times. If "we know how to bill" is the differentiation in the deck, the company is competing on table stakes.

Pricing pressure is structural. When everyone monetizes the same code at a similar PMPM, the only lever is volume — which means a sales-led race against three other companies pitching the same buyer with the same economics. The race-to-the-bottom is not a possibility, it is the default trajectory.

The real moat sits one layer up. What is defensible is the clinical workflow, the outcomes evidence, the partnership graph, and the data flywheel that compounds out of all three. Those are slow, expensive, and hard to copy. They also do not show up in a CPT code. Founders who treat them as the core asset — and treat reimbursement as plumbing — build companies that survive the next compression cycle.

What it looks like when it is working

One team we worked with crossed $20M ARR in a category where half a dozen competitors billed identical codes. Their advantage was not coding. It was an integrated care model with twelve months of outcomes data, deep technical integrations with three EHRs, and a clinical playbook that two of their largest customers had asked them to help standardize across other vendors. The codes were a billing line. They were not the story.

A few questions worth sitting with

• If a competitor announced tomorrow that they billed the exact same codes against the exact same patient population, what specifically about your company would they not have?
• Of the moves on your 2026 roadmap, how many extend what you do above the codes versus optimizing the back office around them?
• When a buyer puts you side-by-side with two alternatives in a procurement spreadsheet, what is in your column that is not in theirs?

If those answers are uncomfortable, that is useful information. The companies we see breaking out of the $10M plateau are the ones that took this question honestly two years before they had to.

— Andrew