Payer & Provider Dispute Resolution
Expert advocacy and negotiation to resolve payment disputes, claim denials, and contractual disagreements while protecting your revenue and relationships.
Resolving Payer & Provider Disputes
Expert advocacy and negotiation to resolve payment disputes, claim denials, and contractual disagreements while protecting your revenue and relationships.
When payer behavior disrupts revenue, delays rightful reimbursement, or creates barriers to care delivery, healthcare organizations need a partner who can respond with speed, precision, and authority.
PayrAdvisors specializes in resolving high-stakes disputes with commercial health plans. That includes underpayments, claim denials, contract breaches, policy misapplications and other disruptions that threaten your financial stability. or patient access.
Backed by deep expertise in managed care contracting, payer regulatory frameworks, and national plan negotiation, our team intervenes decisively to protect your organization’s revenue integrity and enforce your contractual rights. We help providers stand firm against unfair payer practices, achieve resolutions quickly, and restore predictable reimbursement across even the most complex scenarios.
Contractual Underpayments & Misapplied Reimbursement
We aggressively pursue payer underpayments tied to:
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Improper fee schedule application
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Retroactive rate changes
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Misclassified service lines (e.g., HOPD, ASC, office-based)
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Bundling, downcoding, or incorrect payment methodologies
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Network tiering or steerage discrepancies
Our team identifies the root cause, quantifies the impact, and drives payer escalation until the issue is resolved and all dollars owed are recovered.
Claim Denials & Administrative Barriers
We support providers facing elevated or systemic denials related to:
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Medical necessity
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Prior authorization failures
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Site-of-care restrictions
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Policy changes with inadequate notice
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COB, coordination-of-benefits, and eligibility errors
Our experts manage the dispute lifecycle, file formal appeals, engage medical directors, and ensure payers comply with state/federal guidelines.
Policy Challenges & Unfair Reimbursement Practices
When payer policies limit patient choice, restrict physician autonomy, or create anti-competitive conditions, PayrAdvisors steps in.
We address disputes including:
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Forced site-of-care transitions
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Drug acquisition/distribution restrictions (e.g., white bagging, specialty pharmacy mandates)
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Changes to infusion or specialty drug coverage
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Network terminations or unfair contracting behavior
We advocate for your organization through payer escalations, DOI complaints, legal strategy alignment, and coordinated policy responses
Contract Breach & Non-Compliance
Our team evaluates and disputes payer actions that violate:
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Notice requirements
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Adverse reimbursement change clauses
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Timely payment standards
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Credentialing/contracting timelines
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State prompt pay or network adequacy laws
We prepare formal demand letters, negotiate remedies, and ensure payers meet all contractual obligations.
Our Difference
Rapid Escalation & Hands-On Support
We know payer disputes require immediate action. Our consultants engage payers within days — not weeks — and escalate issues to contracting leadership, medical directors, and compliance teams.
Deep Healthcare Payment Expertise
We specialize solely in payer reimbursement, giving us unparalleled insight into payer behavior, policies, and negotiation patterns.
Regulatory & Legal Coordination
We collaborate with your legal team when appropriate and leverage state/federal law to strengthen your position.
Data-Driven Resolution
Every dispute is supported by rigorous analytics, contract modeling, and quantified financial impact.
Common Dispute Scenarios We Resolve
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Chronic underpayment of services, procedures, and therapies across all lines of business
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Out-of-network disputes, balance-billing challenges, and gap exception failures
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Retroactive policy enforcement that conflicts with contract terms or medical necessity
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Revenue recoupments and audits (pre-payment and post-payment), including documentation disputes and coding challenges
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Credentialing failures or delays for new sites of care — hospitals, ASCs, clinics, imaging centers, labs, infusion centers, and physician offices
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Payer carve-outs or carve-backs that reduce rates or redirect services to preferred vendors
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White bagging / specialty pharmacy mandates and other payer-driven site-of-care restrictions
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Improper payment for off-campus departments or newly established service lines
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Rejected contract renegotiations or failed escalation attempts with national and regional plans
Who We Serve
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Physician Groups
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Hospitals & Health Systems
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Ambulatory Surgery Centers
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Ambulatory Infusion Centers
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Private Equity–backed platforms
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National specialty providers
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Laboratories & ancillary service providers
Our Process
Rapid Assessment
We conduct a thorough review of claims, denials, policies, and contract language to diagnose the issue.
Financial Impact Modeling
We quantify the revenue at risk or dollars owed and present a clear roadmap to recovery.
Payer Engagement
We initiate direct discussions with the payer and escalate until resolution is achieved.
Formal Dispute or Appeal
We prepare and submit all required documentation, letters, and policy arguments.
Resolution & Recovery
We secure corrected payments, policy adjustments, or contractual remedies — with full transparency throughout the process.
When Things Go Off Track, We Step In
Identifying the Root Cause
Every dispute has a story. We dig into the details—whether it’s a systemic denial pattern, misapplied contract language, payment inconsistency, or network access issue—to pinpoint the underlying problem and assess the most effective path forward.
Facilitating Resolution
We start with diplomacy. Our payer relationships often allow us to resolve issues directly, avoiding legal escalation or prolonged appeals. We coordinate calls, draft position letters, and guide your internal teams on how to document and respond effectively.
Escalating When Necessary
When informal resolution fails, we’re ready to escalate: Filing formal appeals with payers, Submitting complaints to Departments of Insurance (DOI), Engaging third-party dispute resolution or legal teams when required. Our goal: resolve the issue, recover revenue, and preserve your payer relationships when possible.
Ready to Resolve a Payer Dispute?
Our team is available for rapid intervention and strategic dispute support.
Contact us at:
info@payradvisors.com
Or visit our contact page to schedule a consultation.
Expert healthcare payer negotiation services helping providers secure optimal contract terms and maximize revenue.
Contact
7901 4th St N # 21403
St. Petersburg, FL 33702