Wiki Usual and Customary>

[terry4162]

Good Afternoon - I have a physician asking the following and I'm hoping someone can help me with the correct answer;



We have a patient's whose insurance states that they will pay what 60% of usual customary.



What is usual and customary for in office balloons, Is that 60% of the billed amount or 60% of the paid?



31295/ 31296/ 31297



Thanks

 

[JenniferB7]

When it comes to usual & customary payment (typically seen with indemnity or out-of-network plans), the insurance company usually has a defined range of payment. In most cases, an insurance company will not tell you what their usual and customary range is, but will tell you if your charges fall within their usual and customary range.

For example, let's say Aetna will pay 60% of usual and customary for a tonsillectomy. Your billed charge is $500.00. You can call Aetna and ask if your billed charge of $500.00 falls within the usual and customary range for a tonsillectomy.

• If the answer is yes, then Aetna will pay 60% of $500 and usually the patient is responsible for the remaining 40%.
  
• If the answer is no, then call Aetna again with a lower fee. For example, is $450.00 within the usual and customary range? If so, then Aetna will pay 60% of $450.00 and that patient is usually responsible for the remaining 40% PLUS the $50.00 difference between your billed charge and the usual and customary allowance (unless your insurance contract, if there is one, specifies that you must write this amount off).

I keep calling the insurance until I know how much of my billed charge (within $25) is within the usual and customary range. Then calculate out the insurance and patient responsibilities accordingly.

I hope that helps!

Jennifer M. Connell, BA, CPC, CENTC, CPCO, CPPM