Carla and Nora went to the same hospital and are covered by the same
insurance company. Both ladies are out-of-network for this hospital.
The only difference between the amount covered is set by where they live. Carla lives in CT while Nora resides in NY. Following the insurance company’s payment and two appeals on the basis of UCR** rates the CT based insurer issues additional payment, while the NY counterpart denies.
What happed to the rate calculation? Why does residence makes a difference? What is Usual, Customary and Reasonable (UCR) rate?
The hospital charged the same rate for both. The only difference is the regulatory authority each insurance department represents. UCR is
supposed to be the average rate a professional with like qualifications, training, and practice location charge for the same service.
If you must use an out of network provider be aware of the URC rates.
Out of network:
*Doctors, therapist whom decided not to participate in an insurance network.
Usual, Customary and Reasonable:
** A fee charged by medial professionals with similar training, experience and
geographic location.
Doctors choose not to provide care for a Medicare regulated reimbursement rate.