Task a day insurance--interrelationship of terms/insurance math. What are the usual and customary charges? They are an insurance company determined amount of what the cost of your medical care should be based on the insurance company's calculations. The term comes into play in:
calculating reimbursement rates
calculating meeting deductibles
calculating your out of pocket expenses
While most people wonder how the insurance company comes up with numbers that are consistently lower than actual costs for their usual and customary amounts and while it's a tough appeal to make to the insurance company, if you decide to appeal then include:
1)your information about the going rate for the service you've obtained in your area
2)anything distinctive about the provider you chose eg he has expertise in dealing with patients like me, or he does more for patients with chronic blah blah etc.
3) and make sure you ask the insurance company what year their calculation of usual and customary charges was from (I got results on this one once when I found out that the usual and customary charges were based on insurance company calculations that were years old)
What is not available: Charts of usual and customary charges used by different insurers, to my knowledge are not readily available to insureds for comparison, too bad, it would be relevant in choosing an insurer. The bigger the difference between usual and customary and actual costs, the bigger your outlay will be for out of network providers (reimbursed based on a percentage of usual and customary charges), outlay of money in order to meet deductibles (also based on usual and customary charges) and out of pocket expenses for reaching out of pocket maximums (based on the same insurance calculated usual and customary charges.)
