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How To Maximize Use Of A PPO Health Insurance Policy

Avoid Paying Money In Excess Of Usual, Customary And Reasonable

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An insurer will not pay medical expense above Usual, Customary and Reasonable (UCR) for your geographic area. To get an idea of how this could affect you: If a bill is $1,000, the UCR for that procedure is $800, and your co-insurance is 80%: you will have to pay $160 for the co-insurance feature (20% of $800) plus $200 (the difference between the amount of the bill and UCR.)

The company that gathers data that is used in UCR does not make the numbers available to the general public. Even if it did, each company then applies its own formula to the base data.

If you are concerned that your out-of-network doctor or other health care provider may charge more than UCR, contact your insurance company prior to incurring the expense. Ask how much UCR is for the appointment, test or treatment.

If you and the insurance company disagree, see Arguments To Use Against An Insurer's Denial Of A Health Claim

Also consider speaking with your doctor about lowering his or her fee. Studies show that people who negotiate fees with doctors are successful at least 50% of the time. To find out what Medicare pays for the procedure, see offsite link, look for physician's fee schedule.

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