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In the real world what does " Reasonable and Customary Charges" for health insurance really mean.
Reasonable and Customary Charges
- Thread starter Insuranceman
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U&C as it's known here means the cost of a service in a given geographical area, usually counties. For example, in my area, services performed around the Seattle Metro Area will cost more than the same services performed a 100 miles in any direction. For individual, doesn't matter. For group it can make a difference in premium.
Service cost is established by survey of providers in a given area. In most cases, an average cost is established with a percentage cushion. So U&C in my region usually means 90-95% of the physicans charging for services will be covered by the plan.
Of course, your mileage will vary, but that's how it's done here.
Service cost is established by survey of providers in a given area. In most cases, an average cost is established with a percentage cushion. So U&C in my region usually means 90-95% of the physicans charging for services will be covered by the plan.
Of course, your mileage will vary, but that's how it's done here.
- 4,096
Great topic
I view U&C is the average price for a procedure in a geographical area.
There are some serious problem with how the carriers determine U&C. Look up the scandal/fraud that UHC did in NY.There can be a huge difference from what a urban clinic charges for a procedure and a suburban hospital. If you have an outpatient surgical center that has invested heavy in technology and location you know their charges are going to be higher. Right now there are online tools being developed by the big carriers where you will see the a menu of what the docs are charging.
1st rule is to stay in network.
The future of U&C will it will not exist. The carriers are already working a paying out of network claims 10% above medicare charges. In the next two years this will become standard.
I view U&C is the average price for a procedure in a geographical area.
There are some serious problem with how the carriers determine U&C. Look up the scandal/fraud that UHC did in NY.There can be a huge difference from what a urban clinic charges for a procedure and a suburban hospital. If you have an outpatient surgical center that has invested heavy in technology and location you know their charges are going to be higher. Right now there are online tools being developed by the big carriers where you will see the a menu of what the docs are charging.
1st rule is to stay in network.
The future of U&C will it will not exist. The carriers are already working a paying out of network claims 10% above medicare charges. In the next two years this will become standard.
R&C/U&C is carry over verbiage and rarely has application any more. Most (if not all) carriers now simply pay the same rate they do for par providers and the patient is stuck with the balance.
Patients who go out of network are just making their life miserable and spending way more than is necessary for health care.
Patients who go out of network are just making their life miserable and spending way more than is necessary for health care.
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