Short, specific notes on how insurers actually pay independent practices — and how to check your own numbers.
We read every FLOIR compliance report from 2023 through mid-2026. Not one fine was for underpaying physicians — what the enforcement record covers, and the private remedies practices have instead.
The vendors that reprice and edit medical claims earn a percentage of what they cut — a fee model documented in their own SEC filings, a granted patent, and a public trial record.
Authorization and payment are two separate gates. The gap in the payers' own numbers, the federal rule that makes an MA approval binding, and Florida's 120-day tripwire.
Denial and appeal-overturn rates at UHC, Humana, Aetna and Florida Blue, extracted from their first-ever CMS-0057 disclosures — with the Florida slices and the appeal gap they reveal.
Florida law gives providers a non-waivable 12-month window to claim underpayments from insurers and HMOs, with 12% interest — and most practices never use it.
The 20-, 90-, and 120-day clocks Florida puts on insurers and HMOs, the 12% interest on overdue claims, and how an independent practice can use them.
SB 362 raised Florida workers' comp rates effective 2025. Slow-loaded carrier rates, the 45-day EOBR petition clock, and how any specialty treating work injuries can check.
Appeal windows at Florida Blue, UHC, Aetna, Cigna, Humana and Medicare — a working table with honest confidence caveats and the 12-month statutory backstop.
Do nothing, work it in-house, buy software, or hire a contingency firm — an honest comparison of the four options, and the questions to ask any vendor.
The routine contractual adjustment is exactly where underpayment hides. How to recompute it against your contract — and when to let it go.
One code, two denials: the global-period branch and the bundling-edit branch. The date math, the modifier arsenal, and when no appeal exists.
An auth that exists, an emergency exception, or an elective miss — three different problems wearing one code, with three different plays.
The proof hierarchy that overturns a timely-filing denial, why Medicare's version can't be appealed at all, and when the honest answer is to let it go.
The code tells you nothing by design — the remark code carries the reason. RARC routing, resubmission mechanics, and why a letter is the wrong tool.
The group code, not the denial code, decides who can be billed. CO is never patient money, PR usually is — and QMB patients can't be billed at all.
The afternoon check: pull your zero-balance claims, compare allowed amounts against contracted rates, and read the three patterns that reveal systematic underpayment.