We help overturn all kinds of denials — most commonly, "not medically necessary" which is the most common denial reason, procedure is "Investigational" or "experimental", and less frequently "etiology not covered".

Many of our clients come to us after they've received approval on their prior authorizations or claims but were severely under reimbursed (very common) and are seeking to maximize their out-of-network reimbursement.

We work with any and all carriers — from the big names (Aetna, Cigna, UnitedHealthcare, BCBS, Anthem, Centene, Humana) to smaller regional players. It doesn't matter (so long as you and your plan are in the United States).

We do not serve any person or insurance plan located outside the United States (and frankly, if you're outside of the United States you probably don't have to deal with these issues anyway, lucky you!).

Yes, your PPO will technically “cover” out-of-network treatment, but the real question is, how much will they actually reimburse you?

If you think the answer is simply “whatever the doctor charges, minus your out-of-network deductible and co-insurance,” we hate to burst your bubble.

In reality, when you go out-of-network, insurance carriers rarely use your provider’s full billed amount. Instead, they apply an “allowable amount,” which is often tied to Medicare’s fee schedule.

Unfortunately, Medicare rates can be as low as 5% of what a typical provider might charge.

The result? Even if your out-of-network claim is “approved,” the reimbursement is often $0 (fully applied to your deductible) or a paltry sum that falls far short of expectations.

It’s crucial to realize that an approved prior authorization for out-of-network care is frequently just a “sugarcoated” denial of insurance claim.

At Suade, we work to maximize your reimbursement by getting insurance to treat the claim at the in-network benefit level—typically covering around 70%-80% of your provider’s billed charges (the amount you actually paid).

Yes, we can still help!

If you're looking for support on overturning a medical necessity denial of coverage for a pre-service (prior authorization) or post-service (claim), it doesn't matter if you have an HMO, EPO, or PPO.

If you're looking for support getting maximal reimbursement for an out-of-network procedure, this can be more challenging with an HMO/EPO since non-participating providers are *typically* excluded from coverage, but we're been successful in this area many times despite this limitation.

Reach out to us for guidance, we'll review your case for no-charge and advise you of your best path forward.

We are ecstatic and appreciative of your enthusiasm, and are also eager to see you receive the funds that are rightfully owed to you.

Please remember that insurance carriers can only reimburse you after a claim is filed by either you, or your doctor, and is successfully processed.

Also remember that you or your doctor can only file a claim after the procedure is completed.

From that point, add about 30 days at minimum for claim processing by your insurer/payer. If the claim is a "clean claim", as in all neccessary details are present and it is coded correctly, you can be paid even faster than this.

If not a "clean claim", it can take months to see a reimbursement.

It all depends on who is filing your claim, the accuracy of it, and your carrier's processing times. Note that there are regulatory and contractual requirements for claim processing timelines, please keep this in mind.

Of course you can, and we'd love to see more people out there like you!

The reality is insurance can be very nuanced, and appeals are accordingly difficult to successfully draft because there are many variables that need to be considered when making your arguments.

Variables such as: your contract, unique prior medical history, current morbidities, geographic location, desired treatment, desired physician/surgeon, type of insurance, type of plan, and other unique circumstances that make appeal writing as unique as you!

Check our blog frequently for help in this area, we'll be publishing content to help people draft their own appeals.

If you'd rather "take a load off" and "have the pros do it", we're here for you.

We generally prefer to have at least 45 days-worth of a buffer to allow us sufficient time to assemble your case, however we've turned around approvals in as little as 3 days!

Reach out to us as soon as you've scheduled your surgery or ideally, once you have a definitive timeline for your treatment so that we can get to work and secure a win for you early on.

We help with most if not all major, complicated, or expensive treatments and surgeries.

We got our start with jaw surgery and are extremely well-versed in the intricacies of that particular treatment, but we frequently receive requests for advocacy for bariatric surgeries, spinal fusions, and what may be considered cosmetic such as rhinoplasties and blephroplasties.

Yes — even a rhinoplasty can potentially be covered should it yield a medical benefit to you.

Whatever it is, let us take a look and let you know how we can help make it a reality.

No — we are not attorneys, medical professionals, nor financial professionals.

We are simply advocates that have intricate knowledge of the health insurance system and it's numerous complexities, as well as a solid understanding of state, federal, and contractual obligations afforded to you as an insured person.

Although we are not medical providers, we have a good knowledge-base on various medical procedures to allow us to successfully advocate and fight your insurance carrier (but not to provide you with any medical advice). We are also partnered with a number of attorneys and medical providers.

Please understand that working with us does not establish an attorney-client, doctor-patient, or any other kind of professional relationship. Please work directly with a licensed professional for such matters.