Understand your insurance policy terms and hidden rules before choosing a hospital for an upcoming medical need. If your circumstances dictate the need for an out of network hospital understand the practices behind usual customary and reasonable charges - or you may find yourself in the poor house.
I recently underwent a surgery that required a five night hospital stay. The final bill from the hospital sheds light on an often misunderstood and potentially crippling aspect of medical billing: usual customary and reasonable charges. If you are considering being treated at an out of network hospital, make sure you understand your possible financial obligations.
Many insurance plans provide in network and out of network reimbursement. The typical plan pays a higher percentage of charges for in network hospitals, and a lower reimbursement percentage for out of network providers. What many people fail to realize is that reimbursement levels are based upon usual customary and reasonable charges. If your hospital bills you above these standard rates you may be left with a big problem.
My surgery was performed at an in network hospital, and my insurance paid 100% of the "allowed charges", after I made a daily co payment. The total hospital charges were $61,000, while the allowed charges were only $13,000. The hospital credited a $48,000 contractual adjustment - that's a 78% discount off the retail cost!
When you use out of network providers you lose cost containment: the contractual rate. If this hospital was out of network my insurance would have paid 80% of the allowed charges - or $10,400 leaving me with an unpaid hospital bill of over $50,000. The contractual rate is equivalent to usual customary and reasonable fees and medical providers are free to charge and collect on any differences. In many cases the difference can blow your mind and your budget.
For many, an out of network hospital may be the best option for a healthy outcome. Make sure you know the real cost before making your choice. Hospital indemnity insurance can help as well, and long as your coverage begins before you need it.
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