I am trying to find out where I can find the rates that insurance companies use to determine a reasonable and customary charge. My insurance company has been reducing their payments to the doctor by saying it is over reasonable and customary. I am questioning these amounts, but I can’t find anywhere on the internet this information. Please help?
Thank you.
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Insurers adopt their own methods of calculating “Reasonable and Customary Rates.” Typically, an insurer’s “out of network” rate is based on the average fee for the service charged in a given geographic area, minus a percentage determined by the insurer. The Medicare rate MAY be used, but, unless your state’s laws require it, insurers don’t always use the Medicare rate as an indicator of reasonable and customary. Some insurers purchase fee schedules from other companies. However, all insurers consider their fee schedules to be “proprietary” (confidential information belonging to the insurer, not shared 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 the reasonable and customary payment, and you may be balance billed. If your physician is participating (has a contract) with your insurer, you may not be balance billed, except for co-payments and/or co-insurance (if applicable). If you are being balance billed by a participating physician, contact your insurer and ask that it step in to assist you.
By your description, I infer this is a non-participating provider. In this case, there is little you can do except arrange for future care with a participating provider. You might also contact your state’s insurance commissioner’s office to see if there are any laws applicable to this situation. You should also consider sending the insurer a written appeal and ask that it review its payments to ensure the claims were paid correctly.
I hope this helps.
I think this person has exhausted the power to finnd whaat hes lookin for as i have and have the same need bad can anyone give us the correct path before we let it go and our health pays for it due the fact it gets out of hand then embarrasement stops people from going i am overdue and put it aside but need help yesterday on dental and med dental first and still im so unnder the table with turn aways that my eyes dont even count right now so please any ANSWERS to help
you won’t find these rates on the internet… this information is only available for those who work in the medical field… i work in the medical field.. as an out of network insurance coordinator.. therefore i do understand how the insurances work along with customary and usual… the process is rather a long explanation.. but if you would like to email me… my email address. is .. c_donna1@yahoo.com
Request the customer service rep to recite to you where they are obtaining this information. If they cannot, you should request full coverage. If they are unable to provide you the full coverage tell them you will contact the better business bureau, your state attorney general, and the state agency responsible for handling medical insurance complaints. In California, it would be the department of insurance.
Best of luck.
The medicare payment schedules are a good start, but reasonable and customary may be 3 times that, not 1.25.
The information you want is not available free; company who compile such data publish tables of costs for a high fee.
The doctors know what the insurance companies pay… they often subscribe to services that manage the multitude of managed care contracts they must abide by to have their enrollees coverage paid.
Well, reasonable and customary varies per geographic location, but MOST of the time they are based on medicare rates – usually about 125% of medicare rates. Now, the doctor, in turn, has to accept this “usual and customary” rate, and cannot bill you for the difference. They can STILL bill you for any co-pay or deductible amounts.
You can go to http://www.medicare.gov where supposedly, somewhere, they have published common procedure rates, but it IS going to be state specific.