OON provider within In network practice

[lotus921v]

Obviously out of network providers can bill higher rates that in network providers... If i were to go to perform work with an in network provider while remaining out of network, what difficulties with billing might i see?

[PMRNC]

It's very simple...  In network:  fee schedule.. Out of Network is subject ot U&C / R&C

[lotus921v]

U&c r&c?  Whats that?

[PMRNC]

U&C is Usual & Customary and R&C means same thing it's just called Reasonable and Customary.

[DMK]

It's also important to note that the provider (in or out of network) can CHARGE whatever they want.  That doesn't mean they'll get it.  The fee schedule is set PER insurance company (and all will be different amounts) and U&C is determined by the area the doctor practices in (San Francisco would have a higher U&C than Modesto because the cost of doing business is different).

[PMRNC]

For my pediatric practices and high dollar claims I have our office manager send a request for Pre-D (Pre determination of Benefits) to the carrier if we are NON par. The pre-d specifies the CPT code, diagnosis and date of service (scheduled). The carrier usually sends back simple letter back with YES or NO the fee is within R&C or U&C. They don't tell you (not legally allowed) the R&C amount otherwise doctors would bill up to that amount which is fraud.   We do this with carriers non par with because we can setup a payment schedule with the patient. If the fee is to be cut substantially the provider can decide to write off all or part of the fee that is OVER the R&C. For those we have the patient sign a hardship financial.. just to Cover their butts.