When insurance plans deny coverage – or apply low payments for the medically necessary services – it’s important for patients to understand what is happening and perhaps most important, know their options for recourse.
Usual and Customary is a term insurance companies like to apply on Explanation of Benefits forms. This term is typically printed next to a paid medical service item. For example, a 64999 service item charged at $500 may result in a mere $118 payment from the insurance carrier, accompanied by a notation (e.g. Exceeds usual and customary) next to the billed amount.
Because of this language, it’s common for patients to infer that their doctor is overcharging because their insurance has indicated that the billed amount exceeds the “usual and customary” amount. This is a common insurance strategy to rationalize their low payments. Worse, it creates an unnecessary and incorrect adversarial relationship between patient and doctor.
The fact is, insurance plans with out of network and medical specialty restrictions routinely deny payment based on fiscal decisions – not clinical (medical) considerations. The less expensive insurance plan will want to pay for standard MRI and x-ray based tests like CT or fluoroscopy, since these tests are less costly and will save the expense of not having to reimburse for out of network specialty medical services.
Unfortunately, with more specific medical conditions, the “usual and customary” services provided by one’s insurance plan may not be sufficient for meeting the standard of care. It’s important for patients to not misconstrue what this explanation really means.
We encounter this issue with certain insurance carriers over the issue of MR Neurography. Despite neurography (nerve scans necessary to help identify and treat specific nerve conditions) being an accepted medical practice and technology, to date it lacks an accepted American Medical Association code, resulting in many billing services using “764999,” a catch-all code for “unlisted medical service.” By the time the insurance company receives the bill, they typically reclassify the neurography scan as a standard MRI and pay only that low rate, despite their being no comparison between the technologies and medical expertise between the two scan types.
And, of course, by way of explanation, the insurance company will use the term “exceeds the usual and customary” next to the MR Neurography charge on the Explanation of Benefits.
Fortunately, there is help for this issue. The Institute for Nerve Medicine provides billing appeal assistance to all our patients. We maintain a database of successful appeal letters for your use, and we can help you request an external review of your insurance plan payment. We can even help you request that your local insurance commissioner review the decision for proper payment and reimbursement.
We have more than ten years of experience in not only providing the patented MR Neurography scans for our patients – but also in dealing with insurance companies and billing practices. We are here to help you receive maximum payment from your insurance plan, and most important – we are always on your side.
Please don’t hesitate to call our office at 310-314-6410 or click here to contact us with any questions or concerns.