Reasonable and customary?

[rideon]

What is the name of your state?What is the name of your state?Pennsylvania
I was injured in an off road motorcycle accident.I'm getting billed by the anesthesiologists for $1300.00 and the helicopter transport for $2700.00 which the insurance co. passed on to me as they deemed these charges over the "reasonable and customary" limits.My insurance policy is a PPO.The hospital and doctor belong but the anesthesiologists do not.Also the helicopter came from 100 miles away as the local one was busy.I bought this policy specifically because it was supposed to pay 100% past the deductible,in fact I asked the agent face to face if all bills would be paid 100% as I 've been through this(injuries).before.He said yes .Do I have any recourse against the insurance co.to pay these bills?Thanks in advance

 

[rmet4nzkx]

Check your policy language re out of plan coverage for emergencies or out of area plan coverage? Then look into the plans appeals porcess.

 

[cbg]

In general, even if a policy allows "100%" for out of network charges in an emergency, that only means 100% of what they would have paid a network physician or provider. If the out of network provider charges more than what the network provider would have received, the insurance carrier is not liable for that.

By all means follow Ms. Cupcake's advice but the probability is that you will be liable for the difference between 100% of the R&C charges and the total of the bill.

It's not outside the realm of possibility that the provider might be willing to negotiate the excess.

 

[rmet4nzkx]

They really need to look at all the fine print, especially if any of it concerns high risk activities.

 

[cbg]

Absolutely they do. But my answer is based on probabilities, having worked for a national carrier for five years and having seen this scenario literally hundreds of times.

 

[rideon]

Thanks to all folks responding to my query.I'm not looking for anything extra from the insurance co. than peace of mind that bills were being paid.I guess the next time I purchase insurance,I'll hire a lawyer to explain it to me.Thanks again.

 

[somarco]

Medical transport companies, anesthesiologists, labs, outpatient clinics (primarily chemo & radiation), physical therapists are all considered hidden providers. They rarely participate in any network discounting.

As such they are free to charge whatever they wish.

You can attempt to negotiate with them but they are under no obligation to reduce their fees.

PPO contracts are only good when you use network providers. If your carrier charged an out of network penalty, you should be able to get that waived.

This doesn't make your plight any better, but perhaps this explanation will help you (and others) understand.