Allowable Amounts of coverage

[prn]

What is the name of your state (only U.S. law)? California

How do I find out if an insurance company has paid the same "allowable" amount of coverage to an out of network provider, that would have been paid to an in network providor? My plan clearly says they cannot pay less for the same medical coverage to an out of network providor. Just the initial co pays are 50% rather than 20%.

[ecmst12]

They don't necessarily pay the SAME allowed amount to in and out of network doctors. In network doctors get the CONTRACTED rate which each office will negotiate with the company. Out of network doctors get the USUAL & CUSTOMARY rate which is based on a survey of the billing rates from all the doctors in the area, and may have Medicare's rates factored in as well. With an out of network doctor, they will pay the percentage of the U&C and disallow anything over the U&C. However, since there is no contract in place, the doctor is free to bill the patient for the disallowed amount. So in most cases, the patient's out of pocket costs will in fact be MORE then just the percentage coinsurance that the insurance companies allow. With an in network doctor, the doctor agrees in their contract to write off any amount over the contracted rate agreed on with the insurance company, no balance billing to the patient is allowed.

[lkc15507]

ecmst is spot on. Yet, the phraseology of the original post concerns me. I think to perhaps help to clarify, it's not likely that the "allowable" for a network provider is the same as for an out of network provider. If I understand our poster, he/she is looking for an "allowable" (dollar amount) that is the same whether INN or OON. That is not likely true for all the reasons described by ecmst above. IE, the simple use of the term "allowable" by a plan does not necessarily imply an equal dollar amount for INN and OON providers. lkc15507

[ecmst12]

Exactly; U&C may be more or less then the contracted rate for any given doctor but I would not expect it to be the SAME in any case. In more cases then not, I would actually expect the U&C to be higher then the contracted rate (after all, that's the insurance company's goal in contracting docs in the first place), but even so the patient will have higher out of pocket costs because of balance billing AND higher coinsurance.

[lkc15507]

Yes, I agree. Yet, the strength of our poster's statement in her / his understanding of the plan language makes me wonder if his / her scenario might not be possible. I'm fully aware that plan language can be difficult to interpret, but this poster does not exhibit any doubt. Is it possible that his / her statement should / could be taken at face value and therefore the INN and OON allowables are the same? In which case, I would have to say the the EOB for the adjudicated claim would show the allowable whether or not INN or OON. I mean, if we take that at face value, the allowable on the EOB would be applicable to INN or OON processing, only at the differing percentages the poster mentions. Does that make sense to anyone but me? lkc15507

[ecmst12]

I've seen similar language in plans and it typically means that the plan is not going to allow less then U&C just because a provider is out of network. In fact I am willing to bet that the ACTUAL plan wording is closer to mine then OP's.

[lkc15507]

I bet you're right. I can't imagine a scenario in which our poster is correct, but, given that he / she seems to be sure of the statement, I had to allow for the possibility. Stranger things have happened with health plans. I suspect the definition of UCR is what is at question with our poster. The allowables are surely different. lkcc15507