Question:
Will BTC accept insurances Reasonable and Customary amount as Payment in Full?
I have Aetna PPO and I'm responsible for 30% of Reasonable and Customary (R&C) charges up to a maximum of 4000. However, I'm also responsible for the difference between billed charges and what Aetna considers R&C. Obviously, this could be a substantial amount. Does anybody know if BTC will accept the R&C amount as payment in full? I've tried to ask them but couldn't get a straight answer. I was told that would be discussed after I had been approved but I don't what to take the time to get approved through them only to find out I will have to pay the excess of R&C and will then have to find an "in-network" facility. — Carolyn M. (posted on February 17, 2003)
February 17, 2003
I have received my bills that are my co-pays from BTC and they total about
$4100.00. BTC was out of network for me too. I did find out that they
will make payment arangements with me on these balances. They are supposed
to call me with more information within the next week or so. I say that
$4100 out of $53,000 is not a bad deal at all and I feel like a million
bucks since losing 97 lbs.
— DRutherford
February 17, 2003
Because BTC is out-of-network, they are not contractrally obligated to
accept any amount from your insurance company as payment in full. They can
basically charge any amount and you'll have to pay the difference. Any
"in-network" doctor would most likely accept R&C as payment
in full. Good luck!
— thumpiez
February 17, 2003
I don't know about reasonable and customary, but my $38000 bill with BTC
was negotiated down by my insurer to about $35000.
— scottiemaam O.
February 17, 2003
I too would be out of network on BTC and they didn't want to negociate with
me so I stayed in Network and will be driving 3hrs to my nearest in network
doctor. some are closer but they don't have as good a reputation as the
Houston one. Would have enjoyed being in a hospital that just worked with
obese patiences..would have been one less thing to worry about.
— WLS_Deb
February 17, 2003
My mother had the same worry that you did, but went ahead and had the
surgery anyway (she is one week out). As for me, they kept telling me not
to worry about it, and my 51,000 hospital bill was negotiated down so that
all I am responsible is for 1500.00...but check your insurance....it might
say that they will not negotiate because some insurances do have that
statement ( in the case of my mom) Best of luck to you.
— Kelly P.
February 18, 2003
BTC has always refused to participate in any network. I was all the way up
to pre-op testing before I found this information out. I have since
changed doctors and am glad that I did even with the extra three hour
drive.
— Marcy S.
February 18, 2003
I am an accounts manager for a large physician billing firm and work with
insurance every day. Reasonable & Customary or Usual & Customary
for an insurance co is based on insurance companies nationwide fee scale.
It is not the same scale as physicians/hospitals national fee scale. If
your physician/hospital is not contracted with your insurance (which
guarantees bringing business to your physician/hospital)then you will be
responsible for the difference. If your physician/hospital is contracted,
they will pay an allowable amount and the physician/hospital has to write
off the balance less any copays or deductibles. If they accept the Reas
& Cust amt from you as payment in full, they actually could be charged
by the state/feds for abuse of the system if they do any state or federal
billing. Reason being...if they bill Medicare a specific amt and Medicare
contracts with the medical provider to pay them their allowable amt and the
provider has to write off the balance, but accepts a lessor amt from
another patient who's insurance only paid a certain amount and the provider
wrote off the balance for that patient, then the provider would be ripping
off the state/feds and they could be in high water for that. So legally,
they cannot accept the Reasonable & Cust amount from you, unless they
accept hardship patients where you would fill out hardship forms and this
would have to be filed on your chart in case they were audited by the
state, and I don't know any physician/hospital who would do that with this
surgery especially when they know the situation up front. Also they would
have to extend that same courtesy to every patient. And if that were the
case, there would be no reason to contract with insurance co's to begin
with.
It's the insurance game! Hope this helps shed some light.
— Karla K.
February 18, 2003
What Karla stated is accurate, however, usually the UCR (usual, customary
and reasonable) payment is more than is paid/approved by federal/state
programs therefore it is the doctor's option to write off the balance even
if they are not required to. Even with writing off the balance, the amount
they receive from your insurance company is very likely a larger payment
than they would get from medicare. As to whether they will, only they can
decide. I would not count on it. Normally UCR is determined by the
average of costs charge in that area, as costs do vary drastically across
the USA.
<p>I know that none of my providers for my surgery are in network.
However, I was able to verify that the amount the surgeon bills is fully
covered and almost 100% sure the hospital will be too, based on previous
experience with their charges. I know the anesthesiologist charges higher
per base unit than UCR and expect around $100-150 balance. If they decide
to bill me for the balance I will have to pay it, but they may write it off
since 99% will be covered by insurance. BTC does legally owe you an
estimate of charges so you have an idea what to expect, especially if they
are making you sign that you will cover whatever insurance doesn't.
— zoedogcbr
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