Out-of-Pocket Expense Cap

There's one advantage found in PPO or POS services that isn't found in fee-for-service plans. Both of these plans have what's known as an out-of-pocket expense cap. This cap is the amount you need to pay out-of-pocket for certain medical services or treatments before the insurance company pays for 100 percent of the reasonable and customary fee. These caps are useful when you decide to go outside of the network. For example, if you have met the deductible for your PPO plan, the insurance company will begin paying 80 percent of the reasonable and customary charges of your out-of-network doctor's bills with you paying the remaining 20 percent. Once the out-of-pocket expense cap is reached, the insurance company will then pay 100 percent of the reasonable or customary fee of a provider. It's also important to note that only certain health care items can go toward your out-of-pocket expense cap. To learn more about out-of-pocket expenses, click here.

How to Appeal a Reasonable
and Customary Charge
So, you got a surprisingly high bill from your doctor explaining that your insurance company would only pay for a portion of what he or she charged. What do you do next?

Get an Excuse from Your Doctor
Because insurance companies are aware that not all procedures go as smoothly as possible, a letter from your doctor explaining why he or she had to charge a fee above the reasonable and customary charges may convince the insurance company to pay said fee. The doctor should include any medical records and operative reports that may be pertinent to your case.

Do Some Research
If the insurance company continues to claim that their reasonable and customary fees are in line with those found in your community, start making some calls. Call other doctors within the same specialty as yours and ask what they're charging for the same service you just received. Be sure to be as specific as possible and include any complications your doctor may have incurred. If you find that your doctor's fees are standard for your area, present the new information to the insurance company to see if an adjustment can be made to your bill.

Call for Help
If you aren't making any progress with your insurance company, call your state's division of insurance. While they can't force an insurance company to pay any benefits, they may be helpful in persuading your insurance company into reviewing your claim for a possible adjustment.

For more information on reasonable and customary charges, health insurance and related topics, check out the links on the next page.