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Arguments To Use Against An Insurer's Denial Of A Health Claim

A Claim Denied On The Basis That The Charges Are Not Usual, Customary and Reasonable ("UCR")

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As you are likely aware, with indemnity health insurance plans, you can see any health care provider you want. After submitting the bill, you're reimbursed for a percentage of the charge. Rather than the actual charge, the charge on which the insurance companies base the percentage they pay is a standard they create and call "usual, customary and reasonable."

If an insurance company reduces your claim on the basis that the fee exceeds the amount that is Usual, Customary and Reasonable, you have the burden of proving that the charge is indeed reasonable. It is difficult to know whether you're the fees are actually high for the area where you live or receive treatment, or whether the insurance company is just being stingy and setting their UCR level artificially low.

To learn health care costs in your area:

Step 1. Speak with the insurance company. Ask the insurance company for details about how "Usual, Customary and Reasonable" was calculated in this instance. You may get an answer something like "it's up to our actuaries to make this kind of decision" (an actuary is a number cruncher who sets rates and makes other calculations for insurance companies.) If so, ask what information the actuary used.

Step 2. Contact your doctor, or his or her office manager.

Let the doctor or manager know you're not accusing them of overcharging, but that you are trying to correct a problem with the insurance company. Let the doctor or manager know what the insurance company has said about the charge.

Don't be surprised if the doctor blames the insurance company. Ask her to provide any information she can about the level of her charges and what she knows about what others in your community are charging for the same or similar procedures. Ask for the answer in writing so you can include it in your appeal.

Also consider asking the doctor if she will accept the insurance company's UCR amount as full payment. If so, you won't have to pay the remainder -- only your co-insurance or co-pay. While it is very difficult to get the insurance company to budge, doctors may be more lenient, especially if you and the doctor have a long and pleasant history.

Step 3. Do some more research.

If your doctor doesn't go along with the idea of reducing her bill, and if he or she is unable to provide sufficient information about charges in your area, you will have to do a lot of "leg work" to find out from other physicians in your area what they would charge for the disputed procedure or treatment.

If possible, contact as many doctors or doctors' offices in your area as you can. Ask:

  • What is the doctor's fee for this procedure?
  • How many of these procedures the doctor has done?
  • What is the doctor's training?
  • What is the doctor's experience with conditions like yours?
  • Has the doctor had training beyond the norm which would affect her ability to do the procedure, and perhaps charge more for it?

Confirm what the doctor or doctor's office told you by writing the doctor or her office restating what you were told. Ask the doctor or staff person to confirm the accuracy of what you were told. (This procedure takes more work on your part than just asking the doctor or her staff to write the letter -- but it makes it more likely you'll get the written confirmation you need. After all, you're asking a doctor with whom you don't have a relationship or pay to do you a favor.)

If the doctor or staff won't agree to put the information in writing, explain that you are asking for the information as a result of a denied claim, and that you will use it to bolster your case against the insurance company. This will help prepare the physician in case the insurance company calls to confirm your findings.

Be Persistent!

It is often difficult to get an insurance company to change UCR levels. Still, if you're persistent, the insurance company may be agreeable to making an exception for your particular claim -- if for no other reason, to get you off their backs.


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