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
