How Eliott Dear’s Claims Assassins Approaches Insurance Disputes

Insurance disputes between non-par physicians and major carriers happen every business day. Most of them never get resolved on the merits. The carrier sends an EOB, the practice writes off the difference, and the gap between that payment and the FAIR Health 80th percentile benchmark is never tested. The Eliott Dear / Claims Assassins approach to insurance complaints starts from the premise that the merits deserve a hearing through the right procedural mechanism. This piece is a plain-English walkthrough of that approach.

The Wrong Way to Run an Insurance Dispute

The default response to a non-par underpayment, in most billing operations, is to file an internal appeal with the carrier. The carrier denies the appeal. The billing department escalates to a second-level appeal. The carrier denies that one too. After 90 to 180 days of paper-shuffling with the same insurer reviewing its own decision, the claim closes at the original underpayment amount. That is not an insurance dispute. That is asking the insurer for more money, and being told no.

Eliott Dear and Claims Assassins skip the internal-appeal cycle entirely. Internal appeals are not the procedural vehicle for an actual non-par insurance complaint. Statutory IDR is.

The Statutory IDR Mechanism

State surprise bill statutes (the New York and Texas surprise bill laws, the New Jersey Out-of-Network Consumer Protection Act, and analogues in Connecticut, New Mexico, and Georgia) create a procedural vehicle: an independent dispute resolution proceeding in front of a neutral arbitrator. The arbitrator does not work for the carrier. In New York, the benchmark named in the law is the FAIR Health 80th percentile, drawn from an independent dataset the carrier does not control. The procedural posture is adversarial. Eliott Dear and Claims Assassins approach every non-par insurance complaint by routing it into that adversarial structure on day one.

State IDR is the forum for fully-insured plans. The classification step at intake determines whether the dispute belongs there at all. The full sort logic lives at Eliott Dear on the Claims Assassins Intake Sort.

The DFS Side

On the New York side, the Eliott Dear / Claims Assassins method runs through the Department of Financial Services, which administers New York’s IDR and regulates insurance licenses in the state. A determination carries a 30-day payment deadline. Claims Assassins tracks that deadline on every determination and sends the payment demand when it passes. More on how DFS fits in at Eliott Dear on DFS Enforcement.

The Submission Itself

Every Claims Assassins submission, on every insurance complaint the firm takes, is built the same way. Operative notes establishing clinical complexity. Provider credentials establishing the level of expertise that justifies the charge. FAIR Health 80th percentile pricing pulled by CPT and ZIP. Plan classification documenting which IDR forum the dispute belongs in. Legal argument framing the submission against the specific playbook the carrier is running on that claim type. And an attorney signature.

The Eliott Dear / Claims Assassins approach treats every insurance complaint as adversarial litigation. That framing is why every submission goes out as a full documented package, signed by Eliott Dear under his own bar number. The attorney-signed model is unpacked in Eliott Dear on Attorney-Signed IDR.

Where the Approach Does Not Apply

The Eliott Dear / Claims Assassins method is narrow on purpose. It applies to non-par claims with an underpayment relative to the FAIR Health benchmark, on fully-insured plans that fit state IDR. It does not apply to in-network contractual disputes. It does not apply to medical-necessity denials, which require utilization-review appeals rather than IDR. It does not apply to billing-coordination disputes inside a participating contract. The discipline of the intake gate starts with refusing claims that do not fit the statutory mechanism, so nothing is filed in a forum that cannot hear it.

The Engagement

The way to engage Claims Assassins on an insurance complaint is one EOB at a time. No retainer. No long-term contract. No upfront fee. The fee is 10% of the improvement, due only on dollars above the carrier’s original payment. The full fee logic is at Eliott Dear on the Claims Assassins 10% Contingency. The intake-before-commitment model is at Eliott Dear on the One-Claim Test.