my insurance has a new code

[IslandDreamer]

And it means "we won't pay what this physician charges." Yup, quite literally, "this expense is outside the norm for this procedure."

[Proudmama]

Don't you think they should state what is "out of the norm" before they just decide to code that one up on the bill .

Insurance can be so annoying somethings. They can get away with charging so much and never pay out anything.

[minnesotamama]

Is that legal??

I know with my insurance they have "deals" with all sorts of doctors, so the doctors bill for 100, but insurance says nope, we only pay 80. I don't get charged the difference either. Of course this means they want me to use doctors that they get the best deals with!

Do they at least tell you in advance that you might have to pay more??

[nomore]

This isnt new for us. They ownly pay reasonable and customary charges. Basically no more than a certain amount for something. Although, most insurances have negioated rates with DRs and hospitals anyways. So, it really hasnt been too much of an issue.

[krdoty]

Reason & Customary is actually quite common in the insurance industry. Most of the time if a doctor is contracted to accept your insurance plan then they are contracted to accept whatever the insurance company deems to be R&C, regardless of how much they charge. The doctor is not allowed to charge patients the difference.

R&C is typically only a problem for patients if the doctor in question is an Out-of-Network provider. That's because the those docs are not under contract so there is no way that the insurance company can require them to adhere to standard pricing.

Have you checked with your insurance company to see whether their contract allows docs to charge the extra to you?

[IslandDreamer]

Yup, out of network anesthesiologist for the TL. UGH. I asked and asked and planned and called everyone BEFORE. So bent.

[nomore]

oh... that does suck Im sorry.

[krdoty]

That really sucks. I wonder... Were there other anesthesiologists available at the time of your tubal that were in-network? If so, maybe you can persuade them to lower the bill to meet R&C. You might get some help arguing your case if you contact a patient liaison at the hospital where the surgery was performed.