advertisement
Looking for something on the site? Search for it here! Also see Clark's Greatest Hits

Jan 13, 2009 -- Health insurers' customary charges to be revamped

Since the late '80s/early '90s, Clark has been receiving calls from people in dispute with their health insurers about "reasonable and customary" charges. This is a tactic used by insurers to shift costs away from themselves and onto consumers.

Say, for example, your doctor bills your insurer $100 for a procedure. Typically, the insurer might cover 80% and you would pay 20% after meeting a deductible. But using the guise of "reasonable and customary" charges, the insurer goes back to the doctor and says it's only reasonable for him or her to have charged $50 for the procedure. Suddenly, the insurer is only paying $40 (80% of $50) and you get stuck picking up the remaining $60 tab.

In a massive conflict of interest, insurers were actually using an internal database to calculate what level of reimbursement they would give out-of-network providers for reasonable and customary charges. A new settlement between UnitedHealth and the state of New York, however, will change all that.

Under the settlement, UnitedHealth will pay $50 million to build a more transparent database. In a predictable move, the company admitted no wrongdoing whatsoever.

If you're locked in an ongoing dispute with your insurer, Clark advises the following: Go to other doctors in your area and ask them what they would charge for the procedure in question. That will build a consensus to show that the charge should be closer to what your doctor says instead of what your insurer says -- and that gives you leverage to negotiate.

Unfortunately, Clark won't be able to answer any questions submitted via commenting. If you have a question, please try posting it to our message boards.

Avg. rating: N/A

Add your comment

Security Image * Please enter the code shown at left
what's this?

What others are saying

  • Usual & Cust. fiasco
    Several years ago I had open heart surgery at a hospital that was in my insurance network. Imagine my surprise when part the the anesthesiology bill was not covered because the anesthesiologist was not "in network" and charges were above U&C. They are the only anesthesiology providers in the area. After 2 appeals they covered the charges. Guess my option was to get drunk and bite on a bullet during surgery
  • How to ask for a discount
    The best way to get the charge for a procedure at a doctor's office is to ask at checkout or the billing office. Many doctors will not - and have been advised by their malpractice carriers to not - discuss charges, collections, past due balances, etc. directly with patients. As a patient, you want the doctor focused on providing excellent healthcare - not on collecting your money. Every office should have a fee schedule and a policy for hardship discounts - if you are seeking a discount, state your case to the doctor, but don't pressure them to give you a reduced fee in the exam room.
  • UCR Charges & Assignment
    If a doctor has a contract with an insurer to accept UCR and charges over the UCR amount, it is a violation of that contract to attempt to collect an amount beyond the UCR. He will charge above (this is how the UCR amount gets adjusted from time to time), but he cannot collect aabove the UCR if he has agreed to accept assignment of UCR by contract with the insurer.
  • Customary charges
    I recentlly had knee surgery and for the fun of it I asked 3 different doctors what they whould charge for the surgery. All of them looked at me like I was asking "what is the meaning of life". No one could quote a figure, they all said it depends on.....
  • Who looses when you stay in network?
    The answer is the healthcare provider. As a provider you can charge insurance anything you want, they still pay the same. In behavioral healthcare the Usual and Customary rates haven't changed since 1995 except to be adjusted DOWN. I wonder whether the new database will improve that?
  • Stay In-network
    A good way to avoid these charges is to use Network Providers.

    If you choose to go out of Network negotiate the charges before you receive the treatment. U&C charges are not fun, but insurance premiums are high enough. Forcing insurance companies to pay more only raises the cost. Healthcare is one of the few items that no one asks what its going to cost before they get the treatment. Would you ever buy a house or a car without first asking what its going to cost?
  • Send copy to your State Insurance Commissioner
    If you are having problems with your insurer send a copy of your correspondence to your State Insurance Commissioner. With our first child the insurance claimed that the customary charge was several hundred dollars lower than what it was. We did our own survey and sent it to the State Ins.com.
    It's amazing how fast your insurance co will react when the commissioner starts breathing down their neck.
  • Clark lives in a fantasy world
    Hey clark, your doctors must be different than the ones I know. Just try getting prices for procedures sometime from typical clinics and doctor's offices. They will either tell you falt-out "No", or they will say they only provide that information to current patients.

    Doctors are as guilty as the insurance companies in this cost-shifting game. Neither one wants to queer the deal where with a wink and a nod, the burden of medical costs is transferrred to people with better insurance or fatter bank balances.
send to a friend  view as printer-friendly  RSS feeds
advertisement
advertisement
THIS WEEK'S POLL
advertisement