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Yeah, out-of-network coverage (if provided) is often limited by terms like "the usual, customary, and reasonable amount". When a provider charges unreasonable a
by woobar 8y ago
Yeah, out-of-network coverage (if provided) is often limited by terms like "the usual, customary, and reasonable amount". When a provider charges unreasonable amount the insurance will not have any contracts that enforce the cost of services. And the patient left holding the bag. ;(
My guess is in a situation like this I'd get the reasonable amounts for services provided from my insurer and use them as a basis to refuse any unreasonable charges.
- nerdponx 8y agoThe whole warped part of this is that the consumer has no way to anticipate cost in advance, and often the individual providers (doctors, nurses, etc.) don't either. Shouldn't the burden be on the insurance company to investigate and discourage excessive billing? Or are they too strict as it is, leading providers to play games with billing?
- woobar 8y agoI think in this particular case insurance did investigate actual (or within a reason) costs and paid them. But there is no business relationship between the insurance company and an out-of-network provider. Should they go to the court on behalf of the patient? As a customer I'd like this. But it looks like combining health and legal insurances. Another option is maybe to require that language on the "patient responsibility form" to include the blurb about fair prices. For instance: In the event that my health plan determines a service to be “not payable”, I will be responsible for the complete charge and agree to pay the usual, customary, and reasonable costs of all services provided.
- nerdponx 8y agoIs there an analogy in the car insurance world? Let's say I know nothing about cars and I get in a collision somewhere far away from home. I need a repair th let's say I know nothing about cars and I get in a collision somewhere far away from home. I need some bodywork and a replacement for the flimflam crankslap in the engine. The shop knows that I don't know anything about cars, and they know that I am covered by insurance. What is stopping them from charging me an exorbitant rate for a new crankslap, and then me getting screwed when the insurance won't cover it?
- woobar 8y ago> What is stopping them from charging me an exorbitant rate Nothing. That's why everyone always asks for a good and trustworthy mechanic. Or an HVAC repairman.
- trocadero 8y agoThis is a rare case where the insurance company is entirely blameless. According to the article, they paid much more than what experts say is reasonable for the care provided.