how insurance companies decide how much to pay a surgeron?
Question:
Answers:
If your doctor agreed to a negotiated rate with your insurance company, you are not responsible for the discounted amount. This is a common practice in HMOs and PPOs, and it does not mean that the doctor 'charged too much'.
If the insurance company says you ARE liable for the amount they didn't pay, it means they are using some sort of calculation for the "reasonable and customary" charges for the area (they don't have a contract with the doctor). If they did this, you can ask them how they came up with this calculation and when was the last time they updated it. Some companies just pay a percent of the Medicare fee schedule (110% or 125%), but they might be using old data.
Other Answers:
call your ins and ask if there is a negotiated rate. sometimes it doesn't matter what the doctor wants to charge, some ins will tell them what to charge and how much they will pay. Ask for a Superbill. It will have the codes on it that is "secret" language talk between physicians and ins companies.
Most surgeons have contracts with insurance companies for specific rates for procedures. Some work for individual hospitals and receive salaries.
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