Won't disclose what they pay?

[ItzaJungle]

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

My insurance company said they won't disclose the amount they pay for an out-of-network doctor. The plan pays a flat amount, and I'm supposed to cover the difference, but I was told by a representative that he is not allowed to disclose the amount. I have to first meet the deductible, then, when the coverage kicks in and I receive a bill for the difference, "then you'll know." He said, "That's why it's a good a idea to use a doctor who's in the network."

Is that legal?

[ecmst12]

They can't know what they're going to pay until the bill comes in and they know what is being charged. And the fee schedule for usual and customary charges is a proprietary document which the insurance company has no obligation to release to you.

[ItzaJungle]

thanks for the reply ecmst12 ,

They pay a flat amount, called "the Network Allowance" for every visit, so they do indeed know how much they will pay, they just aren't willing to disclose it to me so that I can know what the difference will be if I go out of network.

This is how they handle things like chiropractic care and psychotherapy where the cost of the visit is the only cost. So, they don't have to tell me, even in this case? Especially since the deductible isn't an amount, it's "four visits" that means I have to go five times before I'll know whether I can afford it or not. ???

[ecmst12]

Even for chiropractic and psychotherapy, different codes can be charged for different services. Chiro has TONS of different services they perform and therapy codes will vary depending on new/established patient and length/detail of appointment. No, they don't have to tell you.

[cbg]

I am unaware of any law requiring them to make your budgeting easier by disclosing proprietary information.