Reasonable and Customary Charges | HowStuffWorks

Publish date: 2022-02-05

The terms "reasonable, usual and customary" refer to charges made by your health insurance provider for a given medical service. A charge is considered reasonable, usual and customary if it matches the general prevailing cost of that service within your geographic area, which is calculated by your insurance company. The insurance company then uses this information to determine how much it's willing to pay for a given service in your area. This means that if your doctor charges above the reasonable and customary charge, you may have to pay the remainder.

This explanation may leave you with a lot of questions. How are these charges determined? How can you find out what your insurance company's reasonable and customary charges are? What insurance plans can you find these types of charges in? And finally, what are your options when you're charged above these reasonable and customary charges?

All of these questions will be answered in this article. First, let's find out how a charge is deemed reasonable and customary in the first place.

Contents
  • How a Charge Is Deemed Reasonable or Customary
  • Customary Charges in Insurance Plans
  • Out-of-pocket Expense Cap

    • How a Charge Is Deemed Reasonable or Customary

    To be deemed reasonable and customary, a charge must be in line with the average charge of the same medical procedures throughout your specific medical community. This community includes physicians, hospitals, laboratories and other providers involved in your care.

    Unlike most aspects of health insurance, there are very few regulations for insurance companies when determining what they consider reasonable or customary. In fact, only a few states even define what constitutes the terms "reasonable, usual and customary" and even fewer have regulations on the methodology used in determining these charges. Some insurance companies use statistics found in national studies of your geographic area in order to determine reasonable and customary charges. These studies include the fees charged by medical service providers such as doctors and hospitals. However, in some cases, insurance companies determine these charges using information compiled by themselves and regulated by no one.

    No matter how they gather the information, insurance companies then chart the statistics from a given area in order to get an idea of an appropriate range for a fee for different services. A common determination of reasonable and customary charges is those charges that fall in the 80 percent range of all providers in a given area. For example, if your doctor charges a fee for a procedure that's above the charge of 80 percent of the providers in that region, then you'll pay the difference between your doctor's bill and the amount the insurance company is willing to pay.

    And while a definition of the terms may be easily found in your policy, the actual method of determining a reasonable and customary charge, along with the percentage of this charge they will pay, is usually not included. Legally, insurance companies must tell you how they determine the charges and how much is charged for a given service. While it varies by state, many states require the insurance companies to comply with this request within 30 days. Some good questions to ask your insurance company are how often they update their reasonable and customary charges, the exact geographic area included in determining your charges, and a general description of how these charges are determined.

    Customary Charges in Insurance Plans

    The use of reasonable and customary charges isn't found in all insurance plans. Instead, these charges are generally applied to fee-for-service plans as well as out-of-network visits in PPO and POS plans.

    In fee-for-service plans, or indemnity insurance plans, you have the freedom to pick which doctors or hospitals you want to use, but the insurance company only pays a certain percentage of the bill. In these plans, the insurance company will usually pay 80 percent of the reasonable and customary charge of your medical service. Therefore, you're required to pay the additional 20 percent of these charges. This amount is known as coinsurance. However, if there's a discrepancy between what your provider charges and what your insurance plan is willing to pay, then you'll be responsible for even more of the bill.

    For example, if your doctor charges $125 for which the insurance company's reasonable and customary charge is $100, the insurance company will only pay 80 percent of the $100, or $80. Thus, you will be responsible for the remaining 20 percent of the bill in addition to the balance above the customary charge, or $45 total in this example.

    In point of service (POS) and preferred provider organization (PPO) plans, reasonable and customary charges don't influence your bill if you stay within the plan's network. When staying in network you're often only responsible for a co-pay. And depending on the service, a deductible. Otherwise, the insurance company agrees to pay 100 percent of the provider's bill. The insurance company is willing to do this because when a provider is in an insurance company's network, he or she has agreed to set fees for a given service. Therefore, an insurance company knows what your service will cost and eliminates the need to apply reasonable and customary charges.

    However, once you go out of an insurance company's network, this arrangement is canceled. Therefore, in order to avoid paying high fees and to keep their overall costs in order, insurance plans will apply reasonable and customary charges to a given medical services you receive out-of-network. Normally, the percentage paid by the insurance company for an out-of-network fee is 80 percent of the reasonable and customary charge. In addition, before you can enjoy an out-of-network benefit, your deductible usually needs to be met, no matter what the service.

    If you want to avoid getting stuck with an unreasonable or noncustomary charge, you may have to make a few calls, namely:

    Out-of-pocket Expense Cap

    There's one advantage found in PPO or POS services that isn't found in fee-for-service plans. Both of these plans have what's known as an out-of-pocket expense cap. This cap is the amount you need to pay out-of-pocket for certain medical services or treatments before the insurance company pays for 100 percent of the reasonable and customary fee. These caps are useful when you decide to go outside of the network. For example, if you have met the deductible for your PPO plan, the insurance company will begin paying 80 percent of the reasonable and customary charges of your out-of-network doctor's bills with you paying the remaining 20 percent. Once the out-of-pocket expense cap is reached, the insurance company will then pay 100 percent of the reasonable or customary fee of a provider. It's also important to note that only certain health care items can go toward your out-of-pocket expense cap. To learn more about out-of-pocket expenses, click here.

    For more information on reasonable and customary charges, health insurance and related topics, check out the links on the next page.

    How to Appeal a Reasonable and Customary Charge

    Get an Excuse from Your Doctor

    Because insurance companies are aware that not all procedures go as smoothly as possible, a letter from your doctor explaining why he or she had to charge a fee above the reasonable and customary charges may convince the insurance company to pay said fee. The doctor should include any medical records and operative reports that may be pertinent to your case.

    Do Some Research

    If the insurance company continues to claim that their reasonable and customary fees are in line with those found in your community, start making some calls. Call other doctors within the same specialty as yours and ask what they're charging for the same service you just received. Be sure to be as specific as possible and include any complications your doctor may have incurred. If you find that your doctor's fees are standard for your area, present the new information to the insurance company to see if an adjustment can be made to your bill.

    Call for Help

    If you aren't making any progress with your insurance company, call your state's division of insurance. While they can't force an insurance company to pay any benefits, they may be helpful in persuading your insurance company into reviewing your claim for a possible adjustment.

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