Q : The doctor charged $3,500.00 for a medical procedure and insurance company only paid $2,000.00 because they say this is the UCR amount. Can they do this and do I owe the difference?

A: Unfortunately, the answer is yes. Medical fees do not always follow "rational" patterns and medical providers are free to charge according to their own fee schedule. To ensure rate stability and uniformity of coverage, UCR fees are established and serve as the maximum allowable charge for all insureds.

Q : Is there anything I can do to reduce or eliminate the difference in the UCR allowed and the actual doctor charge?

A: You can appeal to the insurer to re-evaluate the UCR amount allowed. The insurer may be able to justify additional payments and may also contact the medical provider to reach a compromise fee.

Q : Can I buy a policy that does not pay according to UCR so that I will not have to pay the difference charged by the doctor and allowed by the insurer?

A: Managed care policies (HMO & PPO) pay according to a pre-determined fees schedule agreed upon between the insurer and the medical provider. Thus, the doctor's charge will be paid by the insurer except for the deductible, coinsurance or copay owed by the insured. (Answer from GA Department of Insurance FAQ www.gainsurance.org)

Glossary

Coinsurance is the portion of covered medical expenses you and your insurance company share after you meet your deductible each calendar year. As your share of coinsurance increases, your premium typically decreases.

Co-payment Often called a "copay," it's the flat dollar amount you pay for a specific medical service. Copay plans typically cost more because you're paying for the convenience of knowing what you'll spend each time you visit the doctor or fill a prescription.

Deductible The amount you're responsible for before any benefits will be paid for covered medical expenses. The higher your deductible, the lower your premium.

HSA - Health Savings Account

HDHP - high deductible health plan

Insurance - the transfer of risk from an individual to an insurance company

Network Providers A group of providers who provide care at a predetermined lower rate. Staying in the network is an effective way for you to control your health insurance costs.

Out-of-pocket Maximum The maximum amount you're responsible for each year. The higher your out-of-pocket maximum, the lower your premium. It is typically a combination of deductibles, coinsurance and copayments.

Usual Customary and Reasonable - Most Health plans have established usual customary and reasonable procedures for a particular accident or illness. These usual customary and reasonable procedures also have acceptable costs. If your Doctor performs tests the insurance company does not include in the usual customary and reasonable procedures, you will be charged for them. Similarly, if costs are above the usual customary and reasonable charges you may also be billed for the amount not covered by your insurance. This is a standard method used by insurance companies to determine the amount payable under an indemnity type health contract, e.g. insurer pays 80% and insured pays 20% for covered medical services.