I just have a general question about deductibles. When a patient goes?

Question

out-of-network to see a non-contracted Doctor and the patient has to meet a deductible, can an insurance company apply their fee schedule rates to the deductible, no matter what the Doctor charged the patient, or does the insurance company have to apply to the deductible what the Doctor charged the patient?

For example, if the doctor charges $90 for an office visit, and the insurance company's out-of-network fee is $50, can the insurance company apply the $50 to the deductible or should they apply the $90?

Thank you for your help!

Sorry, I don't mean to confuse, I just need to know how much the insurance company is allowed to apply to a patient's deductible. The full amount or their low fees.

Thank you JippytheJessi!

Answer 1

When you see a non-contracted provider, the insurer will only credit what it considers the "usual and customary rate" against your deductible. I've reviewed literally HUNDREDS of PPO/POS contracts and have yet to see even one that credits the entire charged amount against the insured's deductible.

So in the scenario you proposed, the insurer will apply $50. to your deductible, not $90. In turn, you are responsible for paying the doctor $90. and you still have $50. remaining until you satisfy your deductible.

When you see a non-par provider, you will have to pay up front; "Zippy's" answer is relevent to participating providers only. A par provider shouldn't bill you up front; a non-par provider can do whatever he or she wants to. A non-par provider may agree to send your claim to the insurer for you (they don't have to, since there's no contract with the insurer that they do so); some are nice about it and wait to bill you until the insurer issues an EOB.

Answer 2

I'm a little confused, but I think you would pay the $50 to the insurance on top of the deductible, i.e. deductible is $50, you pay a total of $100 for the visit.

But I'd have to know more about your particular insurance and what their fees are.

Answer 3

OK, you have deductibles, and you have CO PAYs. So if you have a $100 deductible, the $90 gets charged against it. If you go see him again, you have a $50 CO PAY, plus $10 more to pay to hit your deductible.


So if you visit the $90 a visit doctor twice, you pay $100 deductible, PLUS $50 copay, for those two visits, or a total of $150. If you visit a third time, you pay $50, as your deductible was met.

Answer 4

Contracted rate gets applied to the deductible - that's why you should never pay up front before your insurance gets billed.