We find that some operations people accept this denial as gospel, and close the file on those invoices. That is tantamount to making a gift to the insurer. Our office has had over 100 cases of this sort. We started suit in every one of them, and resolved almost all of them successfully. On behalf of one provider we were able to arrange for a national contract with an insurer.
Insurers generally call in companies that compile data on a national or state by state basis.
The reason for that was that they had no data on the charges for that treatment made by competitors in the provider's local area. If your company charges the same rates to each of the patients your case is a good one because it is easy to prove. Allowances are made for preferred provider contracts at a lower rate, especially if the insurer steers patients to their preferred providers. But even where the insurer brings in statistical consulting firms to show rates in the general area, the data is usually not specific to the locality where the provider is located. Thus, in one case where the provider was in Asheville, North Carolina, the insurer had no data for that locality, although it had data for the state as a whole.