A decision-basis contract for auditable LLM-assisted medical billing verification: deterministic rules, verbatim evidence, and fail-closed abstention

Medical LLMs are often evaluated by whether they select the correct diagnosis, but diagnostic accuracy alone does not show whether the model used the case evidence appropriately. We present a behavioral audit of evidence use in medical diagnosis. For each case, we decompose patient information into evidence units, score candidate diagnoses under controlled evidence subsets, and mine low-order interactions in diagnostic margins. Because medical evidence is diagnosis-relative, the audit separates interaction discovery from failure assignment: large or negative interactions can reflect plausible differential diagnosis, while suspicious interactions require robustness checks and clinical review. We evaluate five open-weight LLMs on DDXPlus, CupCase, and MedCase. Across datasets, faithful support and differential conflict or cancellation account for most interaction strength, showing that many evidence interactions are clinically plausible rather than failures. In a DDXPlus-focused blinded five-reviewer 130-item enriched review sample, invalid or shortcut-like cases concentrate in negated or absent findings and clinically local evidence. These results show that accuracy can hide candidate evidence-use failures and motivate role-aware audits for medical LLM evaluation.

As autonomous research agents and AI co-scientist systems push large language models (LLMs) from drafting toward end-to-end manuscript production, the bottleneck shifts from generation to verification. Fluent LLM output can hide fabricated citations, numbers that drift from source tables, and unmet reporting-guideline items; existing tools generate without verifying, and self-critique inherits the blind spots that produce confident fabrication. We describe an architecture pairing generation with verification, resting on three principles: decompose the workflow into self-contained skills, gate every stage transition with halt-on-failure, and resolve each integrity question with the cheapest sufficient mechanism, a deterministic, re-executable check where one suffices and a prose-level probe only where interpretation is unavoidable. This determinism-where-possible split, organized as an integrity-gate taxonomy, is the core contribution. It is realized as MedSci Skills, an open-source toolkit of 43 skills with a 21-detector deterministic tier, evaluated on three public-dataset pipelines (STARD, PRISMA, STROBE) and a seeded-defect ablation. Across the three pipelines every content-hash manifest verified clean and the gates surfaced real defects; on 27 identical injected defects the deterministic gates detected all 27 with no false positives on the matched clean fixtures, whereas a single-prompt LLM reviewer detected 11, its misses in code, bibliography, and style defects the prose hides. Determinism-where-possible verification yields an auditable, re-executable trail that exposes the evidence a human needs to check an LLM-assisted manuscript: feasibility and reproducibility evidence, not a claim of human-competitive quality, which a separate blinded study addresses. MedSci Skills is MIT-licensed and archived (v3.8.0).

Large language models (LLMs) often rely on shortcuts rather than systematic reasoning, raising safety concerns in medical applications. Allowing models to abstain when uncertain improves reliability but introduces a coverage accuracy tradeoff. We propose a two-stage framework for medical hypothesis verification in multiple-choice settings that manages this tradeoff through targeted ontology grounding, applied only when the model abstains. We show that abstention is not random but reflects genuine uncertainty, with abstained predictions associated with lower confidence. Across two frontier models (GPT-5.5, accessed via the Azure OpenAI API, and DeepSeek-R1), the proposed framework improves question-level accuracy by 9.6 percentage points (82.9% to 92.5%) and hypothesis-level accuracy by 4.2 percentage points (92.0% to 96.2%). Our experiments conducted on MedReason and MedQA show that abstention can be repurposed as a control signal for selective reasoning refinement, achieving knowledge-graph-level performance without explicit knowledge graph construction.