Ricochet1a
Well-Known Member
On the subject of "Reasonable and Customary Fees", I pulled the following from a Q&A site whose responder to the topic claimed he is more or less a "professional" in the area.
Insurersadopt their own methods of calculating "Reasonable and Customary Rates."Typically, an insurer's "out of network" rate is based on the averagefee for the service charged in a given geographic area, minus a percentagedetermined by the insurer. The Medicare rate MAY be used, but, unless yourstate's laws require it, insurers don't always use the Medicare rate as anindicator of reasonable and customary. Some insurers purchase fee schedulesfrom other companies. However, all insurers consider their fee schedules to be"proprietary" (confidential information belonging to the insurer, notshared with the public).
If your physician is "non-participating" (doesn't have a contract)with your insurer, he or she is NOT under any obligation to accept thereasonable and customary payment, and you may be balance billed. If yourphysician is participating (has a contract) with your insurer, you may not bebalance billed, except for co-payments and/or co-insurance (if applicable). Ifyou are being balance billed by a participating physician, contact your insurerand ask that it step in to assist you.
It has been my experience that providers have fee schedules that are about 2 to 3 times what is considered to be R&C for a given procedure. It is the classic "high ball" technique of starting off billing negotiations.
As part of a real health care reform, this practice should be made illegal. There should be a "free market" for providers - with the restriction that they can't legally bill a certain percentage above a given percentage of the state's determined R&C amount. The fact that R&C amounts are considered "proprietary" should also be disallowed, and all R&C schedules should be public domain.
The fact that you cannot get a straight answer out of a provider as to how much a procedure will cost you speaks volumes as to the need to change how heatlh care is financed.
Insurersadopt their own methods of calculating "Reasonable and Customary Rates."Typically, an insurer's "out of network" rate is based on the averagefee for the service charged in a given geographic area, minus a percentagedetermined by the insurer. The Medicare rate MAY be used, but, unless yourstate's laws require it, insurers don't always use the Medicare rate as anindicator of reasonable and customary. Some insurers purchase fee schedulesfrom other companies. However, all insurers consider their fee schedules to be"proprietary" (confidential information belonging to the insurer, notshared with the public).
If your physician is "non-participating" (doesn't have a contract)with your insurer, he or she is NOT under any obligation to accept thereasonable and customary payment, and you may be balance billed. If yourphysician is participating (has a contract) with your insurer, you may not bebalance billed, except for co-payments and/or co-insurance (if applicable). Ifyou are being balance billed by a participating physician, contact your insurerand ask that it step in to assist you.
It has been my experience that providers have fee schedules that are about 2 to 3 times what is considered to be R&C for a given procedure. It is the classic "high ball" technique of starting off billing negotiations.
As part of a real health care reform, this practice should be made illegal. There should be a "free market" for providers - with the restriction that they can't legally bill a certain percentage above a given percentage of the state's determined R&C amount. The fact that R&C amounts are considered "proprietary" should also be disallowed, and all R&C schedules should be public domain.
The fact that you cannot get a straight answer out of a provider as to how much a procedure will cost you speaks volumes as to the need to change how heatlh care is financed.
