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Reasonable and Customary Charges


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Hi all.

 

We are going to have to go out of network for CBT therapy. Does anyone know what is considered a "reasonable and customary" cost for this? My insurance will pay 70% of "reasonable and customary", but they WONT TELL ME what that is!

 

Thanks! We are in Los Angeles -- I know that costs may vary depending on area of the country/city.

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Hi all.

 

We are going to have to go out of network for CBT therapy. Does anyone know what is considered a "reasonable and customary" cost for this? My insurance will pay 70% of "reasonable and customary", but they WONT TELL ME what that is!

 

Thanks! We are in Los Angeles -- I know that costs may vary depending on area of the country/city.

 

 

Hi Ifran, is it Anthem Blue cross you are dealing with? They are hard to pin down. I suppose you could throw a number at them. so if CBT is 150.00 a session it's 70% that they would pay, am I correct?

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my insurance (CIGNA) was able to tell me the UCR for certain codes- charge codes given by the therapist. I also think the UCR tables are updated every 6 months or so. I do not know if this information is required by law, thought I have seen where some facilities are required by law to post their charges for standard procedures. It would only seem right that the insurers should be required to post their allowances.

It is based on the Medicare rate in most states, I think, but the charges are not state specific, in that it is particular& proprietary to your ins company.

I would find a code for, say, one hour of CBT- ask the therapist what they normally bill on the receipt; call the ins co & then beg, demand and say you will be writing the insurance board of your state because this is wrong that they will not share this information with you. Notice, I said wrong, not illegal, because I do not know if it is required by law. Be persistent and a little bluffing never hurts.

I have had the experience (not in CA) that most of our first visits with a provider are longer and therefore cost more and are not reimbursed at a good amount. Follow-ups fare much more reasonably. It might cost $580 for first visit and I get $200 back. Follow ups might be $250 and I get $150 back-- these are made up examples.

good luck.

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lfran -- i find this very surprising based on our experience. our insurance told me exactly the U&C based from zip code, i think, and then told me the 70% that they would pay. i just assumed that had to if i was asking. i find it odd that they would not discuss this with you. could it have been that you were talking in services terms and they needed a code?

 

 

our experience is a little different from PowPow in that the inital visit, with a different code, were charged at a higher price but covered more. so -- we i guess we must have still been paying 30%, but perhaps the U&C was higher and our therapist difference was less -- ?? i think we saw this with a few therapists -- that the initial visit cost us less.

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In our experience, our first visit is generally a "double one," wherein the therapist gets a good bit of history, etc. We've had it both in two separate sessions, and in one longer one. Point being, the real "therapy" didn't commence until that background stuff was out of the way, toward the end of the second session.

 

We've never been able to use "in-network" therapists in our area; I'm not convinced they even exist. <_< Personally, I think the "good ones" are so well-utilized and booked up that they don't have to deal with insurance to make a good living, and the insurance companies make the process so onerous, that they chose NOT to deal with insurance if possible.

 

We've generally paid between $125 and $165 per 45-minute session, though, again, the good therapists will sometimes run a little over to benefit the kid and not charge you for that extra 10 minutes. We've also found that the ones in private practice (as opposed to belonging to a therapy group or working for someone else) will sometimes work with you on the charges. For instance, our current therapist posts a standard charge of $125/session, but when we came to a point where we had to wrangle in our costs and told him we needed to step down to once every 3 or 4 weeks, he was willing to reduce his fee so that we could keep bringing DS every 2 weeks. So we currently pay $90/session.

 

Just our experiences: Humana and Aetna were gems in terms of submitting for reimbursement, while United Health Care drove both me and the therapist to distraction, requiring "precertification" for sessions and only approving like 6 sessions at a time, then arbitrarily deciding that after 16 sessions, DS "should have had enough therapy," so they were refusing to reimburse beyond that, etc. Calling into question the professionalism of the provider, etc. I nearly lost it with them! Thank heavens my new job puts us with Aetna, and I've not had any issues with them whatsoever.

 

Good luck!

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Thank you, everyone.

 

Yes, this is the type of info that I'm looking for. The therapist charges in this range (150), but I just have no clue what my insurance considers to be reasonable and customary. It's so frustrating!

 

I'm with Anthem Blue Cross. This is the first time, as I've been with a large HMO for the last two decades, so I just really don't know what to expect. They pay 70% of reasonable and customary, until we hit our max out of pocket, which may be coming sooner than I think, at which point they pay 100% of R&C.

 

Aaargh!

 

We had to go out of network in the DC area. DS's therapist charges $150 for a 45 minute session. When all is said and done, insurance pays $78.75 of that charge, leaving us with $71.25 of the expense. (The insurance's allowed amount is $112.50, and they pay 70% of the allowed amount, leaving us with the rest.)

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