Quick Summary
Proposed Bill Seeks Greater Accountability
A new piece of federal legislation is bringing renewed attention to health insurance claim denials and their impact on patients. The proposed Patient Refunds for Bad Denials Act, introduced by members of the U.S. House of Representatives, is designed to hold insurers accountable for high denial rates and increase transparency across the claims process.
If enacted, the bill would allow the Department of Health and Human Services to impose financial penalties on health insurers whose denial rates reach or exceed 25% in a given year. The base penalty would begin at $10 million and increase by $2 million for each additional percentage point above that threshold.
Importantly, any funds collected through these penalties would be redistributed to individuals covered by the insurer, creating a direct financial impact for affected patients.
Rising Concern Over Denial Rates
The legislation reflects growing concern about the frequency of claim denials and their consequences. Recent data shows that denial rates vary widely across insurers, with some plans rejecting a significant portion of claims.
Public sentiment has also shifted. Surveys indicate that a majority of insured individuals view claim denials and delays as a serious issue, with many reporting personal experiences where coverage was denied for prescribed treatments or medications. For some patients, these denials contribute directly to financial strain and medical debt.
Despite these concerns, policymakers have noted limitations in existing oversight. Federal agencies currently lack comprehensive tools to track denial rates across all types of health plans, particularly self-insured employer plans that are not required to report this data.
Key Provisions and Limitations
The proposed bill focuses specifically on insurers offering individual and group health insurance coverage. It does not apply to self-insured employer plans, which make up a significant portion of the market.
Under the legislation, insurers would be required to submit annual reports detailing their denial rates, giving regulators greater visibility into claim outcomes. The bill also includes provisions requiring insurers to provide clearer explanations when claims are denied due to medical necessity.
Certain denials, such as those involving confirmed fraud or valid coverage exclusions, could be excluded from the calculation. However, the overall goal is to create a more transparent and accountable system for evaluating how claims are processed.
What This Means for Healthcare Providers
While the bill primarily targets insurers, it has broader implications for healthcare providers. Changes to how denial rates are measured and enforced could influence payer behavior, potentially affecting how claims are reviewed, approved, or challenged.
Providers may also see shifts in documentation requirements, communication standards, and dispute processes as insurers adjust to new regulatory expectations. Increased scrutiny could lead to more detailed claim reviews or changes in reimbursement strategies.
At the same time, greater transparency around denial practices may provide providers with stronger support when appealing claims or engaging in dispute resolution.
How Patriot Group Can Help
As scrutiny around claim denials continues to grow, providers must be prepared to navigate an increasingly complex reimbursement environment. Legislative changes, combined with evolving payer practices, can create new challenges in billing, compliance, and dispute resolution.
Patriot Group works with healthcare organizations to strengthen their approach to claims management, address payer-related issues, and improve overall revenue performance. If your organization is facing challenges related to claim denials or reimbursement, our team is available to provide support.
Thomas J. Force, Jr.Vice President of Patient Accounts
A graduate of Arizona State University, having received his Bachelor of Arts in Civil Economic Thought and Leadership, Thomas quickly integrated into The Patriot Group shortly after graduating and has brought a fresh perspective to company strategies and protocols, particularly with regard to patient collections.
Currently, as the Vice President of Patient Accounts, Thomas heads up the company’s Patient Accounts Department and is responsible for overseeing staff and ensuring that patients have a clear understanding of their financial obligations, are treated with respect, and ultimately make payments to further boost our clients’ revenue.
Jennifer ManiaciVice President of Coding
Jennifer is a professional coder certified by the AAPC with over 25 years of experience in medical office settings. She is responsible for overseeing any and all coding issues and is tasked with managing the most complex accounts – namely those concerning highly-specialized out-of-network surgeons who often rely upon unlisted codes in order to bill for their services. In this regard, Jennifer regularly secures GAP exceptions for our clients’ patients (i.e., allowing for in-network benefits for out-of-network services) and negotiates lucrative single case agreements to ensure our clients are afforded substantial compensation for their highly-skilled services.
As part of her responsibilities, Jennifer takes great pride in advocating for patients against payors so that our clients’ patients can rest assured that they will receive the maximum benefits from their plan.
Meredith MonteleoneVice President of Operations
Meredith has worked in the healthcare industry for the past 25 years, having managed all areas of the revenue cycle. Her expertise runs the full gamut of revenue cycle matters, including serving in- and out-of-network parties, professional and facility clients, and clients involved in an abundance of practice areas (e.g., vascular, orthopedic, ENT, general practice/primary care, chiropractic, and surgical).
With her extensive experience, which also includes teaching classes at Hunter Business School since 2004, Meredith is responsible for managing accounts, supervising staff, delegating assignments, and analyzing accounts to ensure our clients revenue is maximized.
Susan O’Connor-Van WinckelVice President of Administration
With more than a decade of experience, Susan is integral to the success of The Patriot Group and its clients. A professional coder certified by the AAPC, and having past entrepreneurial experience, Susan certainly understands the importance of maintaining an efficient and profitable revenue cycle.
With this mindset, Susan serves as the ultimate team player. Aside from being primarily responsible for account implementation and general account management, based on Susan’s expertise, she regularly steps up to address the most complex revenue cycle issues, namely those faced by new clients whose past billing company left their account in shambles.
Farooq WaheedChief Technology Officer
A dedicated entrepreneur, Farooq has actively founded, and participated in the start-up of, several successful health-related organizations, including Patriot International Group, the entity that handles aged receivable collection for The Patriot Group.
Prior to engaging in his entrepreneurial endeavors, Farooq served as a senior software developer with Applied Sciences Group. In this capacity, Farooq designed, developed, and maintained highly scalable software and web applications. With this experience, Farooq, along with his brother Rauf Waheed, has been integral in developing software to promote a more efficient aged receivable collection process that separates The Patriot Group from its competitors. As a result, our clients benefit from the maximum collection on their aged receivables.
Rauf WaheedChief Technology Officer
Much like his brother, Rauf is a serial entrepreneur with substantial experience founding, launching, and scaling businesses primarily rooted in the healthcare sector. Relying on his nearly 15 years of experience serving in high-level strategy and planning roles with Fortune 500 companies such as IBM and CenturyLink, Rauf brings an analytical expertise to The Patriot Group that far exceeds that of its competitors.
This skillset, coupled with his background in software engineering, enabled Rauf and his brother, Farooq, to develop and integrate software designed to promote increased and more efficient aged receivables collection. In applying this software to its aged receivable collections, The Patriot Group has been able to increase its clients’ revenues, while speeding up their revenue cycles.
Robert T. Neuner, Esq.General Counsel
An attorney licensed in New York, New Jersey, and Arizona, Robert has spent the vast majority of his professional career in the healthcare sector since graduating from Brooklyn Law School.
Prior to joining The Patriot Group at the start of 2021, Robert simultaneously served as General Counsel, Director of Mergers & Acquisitions, and as the interim Chief Financial Officer for a medical management services firm that subsequently developed into a sizeable primary care practice in Arizona. During this five-plus year tenure, Robert served as the right hand of that company’s owner and Chief Executive Officer. In this regard, Robert played an integral role in that organization’s exponential growth (its revenues multiplying ten-fold), while ensuring that the operations ran efficiently and compliantly.
Robert relies on this past experience, as well as his previous litigation experience, in order to promote the compliance of our clients. As part of his responsibilities, Robert defends against audits and recoupments/refund demands, provides guidance on carrier policies and applicable laws/regulations, appeals unpaid or underpaid claims, and represents clients in surprise billing disputes.
Michele ForceFounder & Chief Executive Officer
Michele Force has over 30 years of experience as a Senior Executive in Operations, Sales, and Customer Service for a West-Coast technology company with a focus on the insurance industry. She has worked with some of the largest insurance organizations in the country, developing extensive experience in technology infrastructure and techniques to increase client profitability. Mrs. Force has developed significant high-level contacts at various insurance companies and other insurance-related organizations.
As Chief Operating Officer, Mrs. Force manages day-to-day activities and client interface while spearheading technology initiatives within The Patriot Group. She is a polished and experienced senior executive, and her team strives to deeply understand clients' goals, problems, and needs. The better they understand the dynamics of their clients' practice, the better they can help them maximize revenue. Their goal is their clients' long-term success, and they aim to be a trusted, loyal partner who ensures they get the most dedicated and passionate team working for them.
Mrs. Force's focus on customer service and her expertise in the insurance industry have helped The Patriot Group build lasting relationships with their clients. Her dedication to maximizing revenue for clients has made her a valuable asset to the company.
Thomas J. Force, Esq.Founder & President
Thomas J. Force is an attorney with significant experience in the healthcare and insurance industries. Mr. Force's background as a former U.S. Marine, Wall Street insurance litigator, General Counsel, Chief Compliance Officer, and CEO of a revenue cycle company showcases a diverse and extensive career.
His expertise in healthcare revenue collection techniques, appeal strategies, and healthcare compliance makes him a valuable resource in the field. Additionally, his role on the Advisory Board at Hunter Business School, involvement with medical billing and coding students, and frequent speaking engagements at medical associations and healthcare organizations highlight his commitment to education and sharing knowledge in the industry.
Mr. Force focuses on a range of topics, including Effective Out-of-Network Work Flow, Successful Appeals Drafting, The Dangers of Waiving Patient Cost Share Responsibility, The No Surprise Act, and The Federal Anti-Kickback, Stark, False Claim Act, and HIPAA. In Short, Mr. Force has a comprehensive understanding of legal and compliance issues within the healthcare sector. His focus is protecting and defending the healthcare provider, and assisting with the generation of revenue for medical practices.