Out-of-network claims are being systematically underpaid — and most practices never recover what they're owed. I build the appeals engine that changes that.
Insurance companies rely on providers accepting underpayments without question. These aren't mistakes — they're strategy. Here's what's happening to your revenue:
Payers process OON claims at rates they set unilaterally — often far below UCR. They count on you not knowing your ERISA rights or the plan language that governs your reimbursement.
Vague denial reasons. Generic EOB language. No actionable information. They're designed to discourage appeals — not to inform your next step.
ERISA appeal deadlines are strict. Missing them eliminates your right to escalate to federal court. Most practices don't know the clock is running.
Internal appeals are step one — not the end. External review, DOL complaints, and federal litigation are tools most billing teams never use. That changes here.
A systematic, scalable approach to recovering underpaid OON claims — built on plan documents, federal law, and proven escalation strategy.
We request the Summary Plan Description — your legal right under ERISA §104(b). The SPD defines reimbursement methodology, appeal rights, and timelines.
FoundationEvery underpaid claim is mapped against SPD language. We identify discrepancies between what the plan promises and what they paid — and quantify the gap.
IntelligenceAppeals are built on plan document violations, not just clinical argument. We cite specific SPD provisions, applicable regulations, and case precedent.
EscalationWhen internal appeals stall, we escalate: external IRO review, DOL complaint, and federal court referral. Most payers settle before litigation. That leverage is the point.
RecoveryWhether you need a one-time recovery sprint or an ongoing appeals engine, there's a model that fits your practice.
Full-service appeals management for OON underpayments. We handle SPD acquisition, appeal drafting, and escalation from start to recovery.
Get started →We request, analyze, and cross-reference your plan documents against paid claims. You'll see exactly where you're being shortchanged and why.
Get started →Done-for-you ERISA appeal frameworks, denial response scripts, and escalation SOPs your billing team can use immediately.
Get started →Ongoing ERISA recovery support for practices that want a systematic, always-on appeals process without adding internal headcount.
Get started →Equip your billing team with ERISA fundamentals, appeal strategy, and escalation protocols. Live and on-demand formats available.
Get started →Start here. We review your OON claim history, identify underpayment patterns, and deliver a prioritized recovery roadmap. No obligation.
Claim your audit →Ann Mills is a certified medical billing and coding specialist with deep expertise in out-of-network ERISA claims. She's spent years in the trenches — working claims, building appeals, and developing the systems that turn underpayments into recovered revenue.
Claim Recovery Edge isn't a software product. It's a practitioner-led recovery service built on the actual mechanics of ERISA law, plan document analysis, and escalation strategy that gets results.
Plan document-based appeals — every appeal is built on what your specific plan actually says, not generic language.
Federal law leverage — ERISA gives you powerful rights most payers hope you never use.
Systematic escalation — internal appeal → external review → DOL complaint → federal referral. We know the path.
Productized SOPs — reusable frameworks your team can run on any claim going forward.
No fluff, no guesswork — specific strategy, specific citations, specific results.
We'll review your out-of-network claim history, identify underpayment patterns, and hand you a prioritized recovery roadmap. No obligation. No pitch. Just a clear picture of what you're leaving on the table.
No spam. No obligation. Just your recovery roadmap.