usual and customary and out of network denials

The Most Common Denials:
Usual and Customary/Out of Network Denials

 

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Usual and Customary and Out of Network Denials apply to plans where there is no agreement or pre-negotiated payment.  This is usually associated with a non-contracted plan.  As there is no agreement on payment, the method the health plan chooses to cost contain claims payments is by using statistics of what is commonly billed in specific geographical regions and paying a percentage off of this number.  Some important things to know about Usual and Customary Denials, include:  

  1. The Usual and Customary Amount varies significantly among health plans and is usually arbitrary.  Different health plans have different methods of determining what is paid. 

  2. To appeal a Usual and Customary Denial you need statistical information to prove your health plan paid too low or that your physician charged too much. 

  3. A Usual and Customary Denial could also be appealed with the assistance of your physician to prove that a higher reimbursement is due based on the fact that the medical procedure was more involved and detailed than normal.

How do you combat a Usual and Customary or Out of Network Payment Reduction/Denial? The following steps may help.

  1. Review the denial in your policy booklet and verify that their denial is justified. If their reason for denial is unclear, call the customer service unit at the health plan for a more descriptive explanation. Record your conversation and document the name of the individual you spoke with for future reference.

  2. Ask your health plan how they calculate a Usual and Customary allowable?

  3. Verify that the methodology used by your health plan allows a high enough price, based on what your physician charged.

  4. Were there any extenuating circumstances by your physician that would justify a higher payment? 

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