Los Angeles Health Insurance Claims
Reader’s Question:
I recently had an appendectomy. Although the doctor who did the procedure was one of my health insurance’s providers, my insurer refused to pay my full claim on the grounds that the doctor’s bill is higher than what is ‘customary and reasonable’ cost of the procedure. What does that mean? Is there anything I can do about my claim? I live in California.
Marie
Los Angeles, CA
There is always something you can do, Marie.
I think your health insurance company invokes legal basis for ‘customary and reasonable’ cost which can really vary from region to region and state to state. ‘Customary and reasonable’ cost, hen put in simpler words, just means the average cost of the procedure in your area.
On that contention, you can simply ask your health insurance company how they arrived at the ‘customary and reasonable’ cost for your appendectomy. After your health insurance company has given you that information, you can then refer back to medical providers, doctors, and hospitals how much they actually charge for the same procedure. You can also cross examine with the doctor who did the procedure if there was any special procedure done in your case why it was higher than the average fee for appendectomy. This can sometimes happen especially if you had some complications during the surgery which might have caused the doctor to bill you more than the average. You can also account for a possible mistake in other aspects like documentation and many other intervening factors. It might take a while but this is one of the common problems with health insurance companies and policyholders caused by inadequate information or understanding of the health insurance policy. In any case, you an always ask assistance from your health insurance company for them to verify the accuracy of the doctor’s billing.
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