VS Victor Sterling, MS, CHDA Patient Rights Advocate & Medicare Policy Specialist You open your mailbox expecting a routine Explanation of Benefits (EOB) after a necessary medical procedure, only to find an official document stamped with three devastating words: CLAIM DENIED. Below the bold heading, a vague boilerplate sentence explains that the service was deemed … Read more
By Victor Sterling, MS, CHDA | Certified Health Data Analyst & Pricing Arbitrator Specialization: ERISA Appellate Timelines, Statutory Administrative Exhaustion & External Review Compliance Missing a single statutory filing deadline by 24 hours forfeits your legal right to dispute an insurance denial and closes the door to federal court litigation. You open your mail to … Read more
By Victor Sterling, MS, CHDA | Certified Health Data Analyst & Pricing Arbitrator Specialization: ERISA Subrogation Forensics, Third-Party Liability Liens & Settlement Recovery Audits When an injured patient secures a third-party liability settlement, health plans assert subrogation liens to claw back treatment disbursements from the recovery fund. You sustain serious injuries in an automobile collision … Read more
By Beatrice Hall, RN, CCM | Senior Case Manager & Clinical Utilization Reviewer Specialization: Durable Medical Equipment (DMEPOS) Utilization Review, Mobility Assistive Tech & Medicare LCD Compliance Durable Medical Equipment claims—from CPAP sleep devices to custom complex power wheelchairs—are frequently rejected over missing technical compliance metrics that can be overturned on appeal. Your physician diagnoses … Read more
By Victor Sterling, MS, CHDA | Certified Health Data Analyst & Pricing Arbitrator Specialization: Payer-Provider Contract Forensics, Underpayment Adjudication & Commercial Fee Schedule Audits Auditing the contracted allowed rate against the actual insurer disbursement prevents payers from shifting illegal underpayment balances onto patients. You carefully confirm that your surgery or outpatient procedure takes place at … Read more
By Beatrice Hall, RN, CCM | Senior Case Manager & Clinical Utilization Reviewer Specialization: Post-Acute Home Health Utilization, Medicare Conditions of Participation & Expedited Appeals Terminating or denying skilled home health care places vulnerable patients at severe risk of readmission; federal expedited appeals force binding reviews within 48 to 72 hours. Following a major stroke, … Read more
By Victor Sterling, MS, CHDA | Certified Health Data Analyst & Pricing Arbitrator Specialization: Payer Telephony Audit Trails, ERISA Evidentiary Record Building & Call Center Dispute Forensics Maintaining a contemporaneous phone log with timestamps and call reference numbers transforms casual customer support calls into binding administrative evidence. You call your health insurance company to verify … Read more
By Victor Sterling, MS, CHDA | Certified Health Data Analyst & Pricing Arbitrator Specialization: Algorithmic Utilization Review Forensics, Automated Claim Adjudication Audits & Regulatory Compliance Commercial insurers deploy machine learning algorithms to auto-adjudicate claims in seconds; challenging algorithmic denials requires demanding the clinical training datasets and reviewer timestamps. Your hospital submits a reimbursement claim for … Read more
By Victor Sterling, MS, CHDA | Certified Health Data Analyst & Pricing Arbitrator Specialization: Federal IDR Independent Dispute Resolution, Out-of-Network Arbitrament & Chargemaster Forensics When commercial insurers and out-of-network providers deadlock over medical billing rates, federally certified Independent Dispute Resolution (IDR) entities step in to arbitrate fair reimbursement. You undergo an emergency surgical procedure at … Read more
By Beatrice Hall, RN, CCM | Senior Case Manager & Clinical Utilization Reviewer Specialization: Experimental Technology Exclusions, FDA Clearance Verification & External Appellate Defense Insurers frequently dismiss advanced surgical techniques or modern diagnostic devices as experimental, but official FDA clearance and peer-reviewed safety data can successfully overturn these exclusions. Your treating surgeon recommends an advanced … Read more