Have you ever submitted an out-of-network claim to only receive back pennies on the dollar? Out of network claim reimbursement has recently been re-evaluated by insurance companies. The days of 70th, 80th, and 90th percentile payments of the Usual and Customary (U&C) amount are over. Carriers are moving away from usual and customary (UCR) and paying a percentage of Medicare's published rates instead. Most companies are paying anywhere from 110% to 150% of Medicare rates.
Carriers have a number of motivating factors for reducing out-of-network reimbursements; lower payments help insurance companies:
• Obtain greater member in-network utilization (in-network providers are paid at an agreed-upon
• Obtain a greater number of providers who agree to participate in the network by making out-of-network
services cost prohibitive to members thereby depleting the out-of-network doctor patient base.
• Grow the network by greater in-network member utilization.
• Keep health benefits affordable & control cost.