Insurance Claims & Denials

VS Victor Sterling, MS, CHDA Patient Rights Advocate & Medicare Policy Specialist Imagine having what seems like “too much” insurance. You are covered by Original Medicare, but you also have an employer-sponsored health plan through your spouse. You undergo a successful knee replacement, expecting your two massive insurance companies to work together to cover the … Read more

VS Victor Sterling, MS, CHDA Patient Rights Advocate & Medicare Policy Specialist When standard, first-line treatments fail for conditions like refractory cancer, rare autoimmune disorders, or complex neurological syndromes, specialist physicians routinely turn to off-label prescribing. This practice involves using a drug that is fully approved by the U.S. Food and Drug Administration (FDA), but … Read more

VS Victor Sterling, MS, CHDA Patient Rights Advocate & Medicare Policy Specialist Imagine experiencing sudden, excruciating chest pain, shortness of breath, and tightness radiating down your left arm. Believing you are having a life-threatening heart attack, you rush to the nearest emergency room. After hours of blood tests, EKGs, and monitoring, the physician delivers unexpected … Read more

VS Victor Sterling, MS, CHDA Patient Rights Advocate & Medicare Policy Specialist You have exhausted internal appeals, submitted letters of medical necessity from your physicians, and complied with every administrative hoop your health plan demanded. Yet, the insurance company continues to stall, issue circular denials, or outright refuse to review critical clinical evidence for your … Read more

VS Victor Sterling, MS, CHDA Patient Rights Advocate & Medicare Policy Specialist Few moments in healthcare are as distressing as standing at a pharmacy register, holding a prescription for critical medication, and hearing the pharmacist say: “Your insurance denied coverage, and the out-of-pocket cost is $1,200.” When a Pharmacy Benefit Manager (PBM) rejects a lifesaving … Read more

VS Victor Sterling, MS, CHDA Patient Rights Advocate & Medicare Policy Specialist When an insurance company rejects coverage for an expensive diagnostic scan, prescription drug, or surgical intervention, most patients write an emotional response. They explain how much they need the treatment, how long they have been loyal policyholders, or how unfair the denial feels. … Read more

By Victor Sterling, MS, CHDA | Published in Healthcare Financial Advocacy & Patient Rights Executive Summary: If you receive a bill months or years after a doctor’s visit because your insurance company denied the claim for “exceeding timely filing limits,” you are usually not legally obligated to pay. Health insurance contracts require medical providers to … Read more

By Victor Sterling, MS, CHDA | Published in Healthcare Financial Advocacy & Patient Rights Executive Summary: When a health insurance company denies a vital surgery, MRI, or specialty medication, written appeals can take weeks or months. However, there is a fast-track clinical backdoor known as a Peer-to-Peer (P2P) Review. This direct physician-to-physician phone call allows … Read more