A more complete answer should be provided by the agent who sold the
policy you are referring to or the insurance company. They should
explain the EXACT policy provisions to the insured as applied in the
state in which he/she lives. The insured has every right to expect a
complete explanation in writing.
I suspect that the primary factor in this case (at least on the
little information I have to go on) is the result of a provision in
many policies known as "Usual, Customary and Reasonable" or UCR.
(What you referred to as the "nation average." By the way, who told
you this was the average and where did they get their figures? Even
the in-network providers may not agree with the results.)
UCR allows the insurance company to determine what is a
reasonable cost for the proceedure that was performed. UCR is a
common provision in policies that have an "in-network" /
"out-of-network" co-insurance.
This is different from "repricing" by the provider. The
insurance company may be making it appear that $1000 was "repriced"
through renegociation, when more likely the repricing is the maximum
the insurance company will pay for said procedure.
When an insured goes to an in-network provider, UCR is relatively
meaningless because the provider has a contractual agreement to accept
from the insurance company payment in full based on prenegociated
costs. The insured is protected from having to pay any balance due by
virtue of having coverage with that company.
To use your situation as an example(assuming that in-network is
covered 100% by the insurance company):
Medical bill = $1000
Provider is in-network,
insurance company remits payment of negociated price = $500.
Balance due to provider by insured = $0
When a procedure is performed out-of-network, there is no
contractual agreement between the insurance company and the doctor.
If the insurance policy has a UCR provision, this means the company
will review an out-of network bill, determine usual, customary and
reasonable charge, and then pay the UCR charge based on the
co-insurnce of the insured's policy (in the case you describe as I
understand it, 80% of the UCR rate.)
Again, using your situation as an example:
Medical bill = $1000
Provider is out-of-network,
insurance company determines UCR cost of procedure to be $500
insurance company pays 80% of bill
Balance due to provider by insured = 100% of the difference
in the original bill and the amount paid by the insurance company
Keep in mind the patient is responsible at all times for the cost
of services. A provider has every right to accept payment in full.
(In fact, doctors, clinics, etc. have patients sign paperwork
declaring who is going to be financially responsible for the cost of
service.) Insurance is a means of sharing the risk of financial harm.
Not all insurance companies have a UCR provision. Nonetheless it
is a perfectly legal provision in the policy. If it were not, your
state department of insurance would not allow that company to do
business in your state. (States govern most policy provisions.) The
problem lay in the fact that it is not a provision that affects the
average consumer until someone goes out-of-network for services. The
plus is that is is a way or insurance companies to control claims
costs and thus help keep down the cost of premiums.
The good news/bad news is that the provider has accepted total
payment of $500 on a bill in which they are legally entitled to $1000.
You may not want to rock the boat there.
I would suggest you find out the exact amount of the UCR to
determine if the insurance company has paid the full amount of the
co-insurance.
good luck! |
