Question
QUESTION: If is a claim denied, would I have to pay "list price" of a procedure or the insurance company's negotiated rate?
For example, if a procedure costs $10K and the insurers negotiated rate is $5K, would I pay $10K or $5K?
Is there a clear standard for how this works?
ANSWER: Hi Spencer!
It depends-------your Explanation of Benefits that showed that your claim was denied will show you what amount you are responsible for. Look under "patient liability". If it does not show on your EOB, then call your insurance company and ask.
If the provider billed your insurance company a negotiated rate than that is the only amount they can bill you if you carrier denies........they have to charge you what they charged the insurance company.
If they billed your insurance company their UCR (usual and customary rate) but would accept a negotiated rate if your insurance company paid, then they can charge you the higher amount.
Hope this helps!
Good Luck!
Tricia
---------- FOLLOW-UP ----------
QUESTION: Thank you for your thoughtful and thorough answer.
Hypothetically, let's say the provider charger a UCR and I approached my insurance company and asked what they would typically pay. And, then approached the provider with that as a negotiating target, do you think I would have any chance of success?
Answer
If your insurance carrier denies a procedure and you either know a negotiated rate or if you are aware of what the insurance company would have paid per their contract, you can go to the provider and request that you pay this amount.
Many providers will do that for a patient who insurance company denies. We have done that at the medical company I work for as a courtesy to the patient.
So give it a try..........definitely worth a shot!!
And you are welcome!!
