I saw WePow's post below, but I don't want to hijack that thread...

I've been seeing new T for about 5 sessions now, and I think I'm finally to a point where I'm beginning to feel some connection. I like her.

She does not contract with insurance, so I pay her rate and then file a claim.

My insurance pays 60% for out-of-network providers...but I found out today that they only pay 60% of TODAY's average rate for providers in my zip code. My T charges $125/hr.

My first claim, insurance paid 60% of $125.

My second claim, they paid 60% of $87 because that was the average rate for that day in my zip code.

Has anyone ever heard of such nonsense??

I called to ask them how am I supposed to plan for my care when the going rate changes daily?? I could be paying $50-$75 per session out-of-pocket?

Not to mention, my T is in a different zip code where the going rate is much higher.

So it makes no sense to me whatsoever.

[darkrunner]

Thats crazy! I've never heard of that one before. But I'm not surprised because insurance companies do crazy things these days.

What did your insurance company say, when you asked them how you could plan your fianances? I'm sure they weren't real helpful, just curious about how they responded.

Do you know where/how the average rate is determined? Is the rate made public, like in the newspaper or online or something? Because I'm wondering if your T would be willing to be 'flexible' about the day that you see her. Meaning, that if you see her on a Tuesday, and then at the end of the week the cheapest average rate ended up being on a Wednesday, you could file your claim saying the session was Wednesday.

Also, have you talked to your T about helping with this? Maybe she would be willing to put a cap on how much you pay, regardless of how much the insurance company pays. SO if she would agree that you could pay $50 per session you could plan for that. And if the insurance is paying her based on a $125 rate or a $87 rate it wouldn't affect your payment, but your T would be paid less. It would be kind of like a sliding scale type of concept.

I guess if all else fails, you have to budget for the largest amount, and if one week you don't have to pay that much, consider it 'extra' money to save.

Sorry if none of this is helpful. I'm really glad you are connecting with the new T and that you like her so much. I hope things work out with the insurance craziness.

[ECHOES]

The amount that the reimbursement is based on generally changes quarterly, based on reporting and is based on a large geographical area based on a range or zip codes. That is how they apply Reasonable & Customary (R&C) or Usual & Prevailing (U&P) or whatever your insurance comapny may call it. All professional services are paid at the Customary or Prevailing fee rate for the geographical area in which the service is performed--medical doctor visits too. This way they reimburse consistently and how expenses are limited to a reasonable amount. A provider can charge $52,225 for an office visit, but reimbursement is limited to the R&C or U&P amount.

The reason they paid more for the 1st visit is because an initial visit is more complex, and is billed with a different procedure code than subsequent visits. How they paid the subsequent visits is how they will probably pay the remaining visits.

Originally Posted by ECHOES

The amount that the reimbursement is based on generally changes quarterly, based on reporting and is based on a large geographical area based on a range or zip codes. That is how they apply Reasonable & Customary (R&C) or Usual & Prevailing (U&P) or whatever your insurance comapny may call it. All professional services are paid at the Customary or Prevailing fee rate for the geographical area in which the service is performed--medical doctor visits too. This way they reimburse consistently and how expenses are limited to a reasonable amount. A provider can charge $52,225 for an office visit, but reimbursement is limited to the R&C or U&P amount.

The reason they paid more for the 1st visit is because an initial visit is more complex, and is billed with a different procedure code than subsequent visits. How they paid the subsequent visits is how they will probably pay the remaining visits.

That all makes sense, Echoes. But this was not what the insurance rep told me.

All my appointments have the exact same procedure code, same diagnosis code, and yet each one is being reimbursed at a different rate based on the going rate for that particular day.