Insurance Denials & Billing Fights

Insurance companies deny claims for a reason: most people give up. They deny valid claims routinely — knowing that patients, still recovering, will not have the time, energy, or expertise to appeal within the window. They send surprise bills months after care was received, hoping the patient pays rather than fights. And they do it because in many cases, the appeal succeeds — but only if it is filed correctly, with the right documentation, within the deadline.

The Patient Advocate Group builds the appeal for you. We pull the medical records, obtain the ordering physician's notes, request the medical necessity documentation, and cite the applicable coverage policy language, state insurance regulations, and (where relevant) federal ERISA protections. We draft the appeal letter, respond to requests for additional information, and escalate to the plan's grievance department, the state insurance commissioner, and — where the facts warrant it — to legal counsel.

What we fight — and often win:

• Prior authorization denials — surgery, imaging, specialist consults, durable medical equipment, prescription medications denied on the theory that they are "not medically necessary."
• Post-service claim denials — the care was already delivered, then the insurer refuses to pay, leaving the patient exposed to the full bill.
• Out-of-network surprise billing — emergency care, anesthesiologists, radiologists, or pathologists who were not part of the network the patient believed they were using. The No Surprises Act protects patients from many of these bills; enforcing it takes documentation and follow-through.
• Balance billing after in-network care — the provider bills the patient for the difference between what the insurer paid and what the provider charged, in violation of the contract.
• Coding disputes and duplicate charges — line items that don't match the care delivered, codes that trigger higher billing, services billed twice.
• Medicare and Medicaid denials — different appeal processes, different deadlines, but the same principle: the initial denial is not the final answer.

Bad-faith denial by an insurance company is a legal cause of action in most states. When we document a pattern — repeated denials of clearly covered services, failure to respond within statutory deadlines, misrepresentation of policy terms — we build the record that turns a single grievance into a regulatory complaint and, where warranted, a lawsuit. Insurance companies know the difference. That's why the pattern-of-behavior letter, on the record, moves cases that a single complaint would not.

You do not have to become an expert in insurance regulation to fight your denial. You do not have to spend the fifteen hours it takes to build the appeal. And you should not have to pay a bill you don't owe just because the insurer is counting on you giving up.

Keep your loved one's safe in the ER

The ideal situation is to have an experienced ER nurse accompany you to the ER. Sometimes we can make that happen. When we can't we can be on the phone with the nurse manager and hospital administrator to make sure things are happening that need to happen.