Location: California
I’m currently in an open enrollment period with my company, where I have two fairly similar options for insurance. One is an Aetna PPO and the other is a UHC PPO. At a high-level, the coverage is essentially identical.
I see an out of network therapist on a weekly basis and I’d like to maintain my relationship with this healthcare provider. For both the Aetna and UHC plans, out of network outpatient mental health is covered with a 30% co-insurance. While I’m comfortable paying 30% of the therapist’s costs, I know that both insurers use a “Reasonable & Customary Rate” and a “Maximum Allowable Amount” to cap my provider’s bills at a certain amount and then I’ll be balance billed for the rest. I’m attempting to find out what both insurer’s maximum allowable amount is for my particular CPT Code / Provider’s Zip Code and found it pretty challenging.
When I spoke with Aetna on the the phone, they insisted that the R&C rate and the Maximum Allowable Amount are the same. In my prior experience, I’ve found that the Allowable Amount is usually a percentage of the R&C Rate and not the same.
When I spoke with UHC on the phone, I eventually was routed into their Behavioral Claims Department who understood what I was asking, but couldn’t provide any information since I’m not a current member of UHC. Apparently, they are required to document all conversations and since I’m not a current member, it would be a HIPAA violation for them to document the conversation. They offered to redirect me to member services, but my experience with member services is that they often don’t understand what I’m asking for.
As a prospective customer for both Aetna & UHC, I believe I should be able to determine how much a service will cost before I sign up with an insurer, but it seems like insurance company’s phone trees aren’t well structured to answer the kinds of questions I’m asking.
I’m hoping the experts here help me figure out the best way to determine which plan will have the lowest out of pocket cost for me prior to signing up for a plan. Any advice?
submitted by /u/Holiday_Cardiologist
[link] [comments]
Location: California I’m currently in an open enrollment period with my company, where I have two fairly similar options for insurance. One is an Aetna PPO and the other is a UHC PPO. At a high-level, the coverage is essentially identical. I see an out of network therapist on a weekly basis and I’d like to maintain my relationship with this healthcare provider. For both the Aetna and UHC plans, out of network outpatient mental health is covered with a 30% co-insurance. While I’m comfortable paying 30% of the therapist’s costs, I know that both insurers use a “Reasonable & Customary Rate” and a “Maximum Allowable Amount” to cap my provider’s bills at a certain amount and then I’ll be balance billed for the rest. I’m attempting to find out what both insurer’s maximum allowable amount is for my particular CPT Code / Provider’s Zip Code and found it pretty challenging. When I spoke with Aetna on the the phone, they insisted that the R&C rate and the Maximum Allowable Amount are the same. In my prior experience, I’ve found that the Allowable Amount is usually a percentage of the R&C Rate and not the same. When I spoke with UHC on the phone, I eventually was routed into their Behavioral Claims Department who understood what I was asking, but couldn’t provide any information since I’m not a current member of UHC. Apparently, they are required to document all conversations and since I’m not a current member, it would be a HIPAA violation for them to document the conversation. They offered to redirect me to member services, but my experience with member services is that they often don’t understand what I’m asking for. As a prospective customer for both Aetna & UHC, I believe I should be able to determine how much a service will cost before I sign up with an insurer, but it seems like insurance company’s phone trees aren’t well structured to answer the kinds of questions I’m asking. I’m hoping the experts here help me figure out the best way to determine which plan will have the lowest out of pocket cost for me prior to signing up for a plan. Any advice?
submitted by /u/Holiday_Cardiologist [link] [comments]Read Morer/HealthInsurance