Have Your Insurance Define “Usual Reasonable And Customary”

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Have Your Insurance Define “Usual Reasonable And Customary”

Most insurance plans will pay only what they call a “reasonable and customary fee” for a particular service. If your doctor charges $2,500 for a colonoscopy, while most doctors in your area charge only $1,500, you will be billed for the $1000 difference. This is in addition to the deductible and coinsurance you would be expected to pay. To avoid this additional cost, ask your doctor, hospital or billing department how much the procedure will cost and find out if the providers accept your insurance and if your insurance has them on their list. You may have to ask for the diagnostic code for the procedure and call other providers to get a sense of what the customary charge is for that procedure in your area and go back to your insurance company with your findings. Be sure to document the date, your insurance contact's name and contact information. If you can, try to get their answer in writing before you continue with the procedure, or even with the insurance, thus, if you are denied coverage in the end, for something you were told was approved, you have the documentation and you can appeal to your insurer. If you do not get results, you can then go to the state department of insurance with all your documentation in hand.
Even if you lose your battle against your insurance company, your message will start to be heard and you can start investigating other insurance companies “who play fare," and be sure to start writing letters to elected officials and key executives at your insurance company.



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Mary White