How to deal with reasonable and customary fees?

Question

My daughther is 7 years old. She was admitted to a hospital for a brain surgery. The hospital took my insurance information at admission and I thought that was all I should do. But things turned out bad. I received insurance statement later that it says some of the doctors are out-of-network. So I have to pay 35% customary and reasonable fees for all services out-of-network. I have no choice but to pay them. But I do not think I should pay anything above customary and reasonable fees, which my insurance and I had paid already. Because all the medical care services were ordered by hospital, including surgeon. And neither hospital nor doctors came to tell me that the particular doctors did not accept my insurance. If they told me before hand, I would have had thought about whether I would allow that service or considered alternatives. They simply billed the amount above reasonable fees to me. My questions are: what should I do? Any impact on my credit?

Answer 1

If the doctors are not employed by the hospitals, it is irrelevant whether or not the hospital is in- or out- of network. When you go through the admitting process, the hospital is concerned with the hospital itself.

After the patient is discharged, you receive bills from independent doctors, radiologists and other health care providers.

Your first step is to file an appeal with your insurance company, but you must file an appeal for each individual provider. So, if you have have two separate doctors bills, file two separate appeals..

Send a copy of your appeal to the doctor's office so they know you are not simply ignoring your bill from them.

If the apply is denied, contact each health care provider to whom you owe money. Explain that you are not in the position to pay the full amount due. Ask them to discount the amount you owe and set-up a payment agreement.

If you ignore these bills, the medical providers will send the accounts to collection agencies. That will cause you hassle and effective your credit score. The most important thing to do is stay in touch with the medical providers' account managers.

Best wishes for the health of your daughter.

Answer 2

Unfortunately you are on the hook for these charges,

You could call each doctor involved to see if they will accept the payment or a reduced payment given the situation.

Not all doctors in a given expertise accept all insurances. I think that your surgeon works with a team of doctors and they are the best at what they do. why would you think about it would you not the best people working on your daughter?

Yes it will affect your credit if you do not pay and these charges the collection agencies are not going to give up. Doctors offices are the worst, because they have people skipping on them all the time.

Call the doctor's offices and see what you can work out.

I hope your daughter is now okay.

Answer 3

Well, if the HOSPITAL is in-network, your insurance company has to treat all of the hospital providers as in network.

You need to appeal the claim decision with your insurance company, in writing.

Any impact on your credit?  Not if you appeal and win.  If you appeal and lose (and I don't see why that would happen) you'll be expected to pay, or yes, they'll put you through to collections.

Answer 4

Reasonable & customary is an insurance term. The amount is set at a level that helps keep the premium affordable to the employers.

I have seen the same insurance company with various fee schedules, and each one was refered to as reasonable & customary.

Insurance companies make the rule as they go along.