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 they apply the $50 to the deductible or should they apply the $90?

Thanks for your help!

Answer 1

It all depends on their little handbook they send you! I just got done buying new insurance and the company I signed will only count the $50 they would of paid to an in-network doctor. That seemed to be a general thing across all the ones I looked at.

Answer 2

Generally speaking you'll pay your deductible, the insurance company will pay what their fee schedule calls for, and you'll pay for anything left.

An example: you have a $50 deductible, then a 20% co-insurance. You go to the doctor and they charge $200 for something. You pick up the first $50, right? Perhaps the usual and customary charge at the insurance company is $150. They'll pay 80% of $100 (the $150 UCR charge less the $50 deductible you already paid), or $80. Because the doc is out of network, he/she doesn't have to limit charges to the insurers UCR, so you're on the hook for anything greater than the UCR - another 50 bucks in this case. So you wind up paying the $50 deductible, $20 for your coinsurance, and the $50 the doc charges in excess of the UCR. Your total cost: $120.

Bottom line: stick to network providers.

Answer 3

I get confused with insurance stuff. Call your insurance company and check with them how it works.