Question:
Will BTC accept insurances Reasonable and Customary amount as Payment in Full?

I have Aetna PPO and I'm responsible for 30% of Reasonable and Customary (R&C) charges up to a maximum of 4000. However, I'm also responsible for the difference between billed charges and what Aetna considers R&C. Obviously, this could be a substantial amount. Does anybody know if BTC will accept the R&C amount as payment in full? I've tried to ask them but couldn't get a straight answer. I was told that would be discussed after I had been approved but I don't what to take the time to get approved through them only to find out I will have to pay the excess of R&C and will then have to find an "in-network" facility.    — Carolyn M. (posted on February 17, 2003)

February 17, 2003
I have received my bills that are my co-pays from BTC and they total about $4100.00. BTC was out of network for me too. I did find out that they will make payment arangements with me on these balances. They are supposed to call me with more information within the next week or so. I say that $4100 out of $53,000 is not a bad deal at all and I feel like a million bucks since losing 97 lbs.
   — DRutherford

February 17, 2003
Because BTC is out-of-network, they are not contractrally obligated to accept any amount from your insurance company as payment in full. They can basically charge any amount and you'll have to pay the difference. Any "in-network" doctor would most likely accept R&C as payment in full. Good luck!
   — thumpiez

February 17, 2003
I don't know about reasonable and customary, but my $38000 bill with BTC was negotiated down by my insurer to about $35000.
   — scottiemaam O.

February 17, 2003
I too would be out of network on BTC and they didn't want to negociate with me so I stayed in Network and will be driving 3hrs to my nearest in network doctor. some are closer but they don't have as good a reputation as the Houston one. Would have enjoyed being in a hospital that just worked with obese patiences..would have been one less thing to worry about.
   — WLS_Deb

February 17, 2003
My mother had the same worry that you did, but went ahead and had the surgery anyway (she is one week out). As for me, they kept telling me not to worry about it, and my 51,000 hospital bill was negotiated down so that all I am responsible is for 1500.00...but check your insurance....it might say that they will not negotiate because some insurances do have that statement ( in the case of my mom) Best of luck to you.
   — Kelly P.

February 18, 2003
BTC has always refused to participate in any network. I was all the way up to pre-op testing before I found this information out. I have since changed doctors and am glad that I did even with the extra three hour drive.
   — Marcy S.

February 18, 2003
I am an accounts manager for a large physician billing firm and work with insurance every day. Reasonable & Customary or Usual & Customary for an insurance co is based on insurance companies nationwide fee scale. It is not the same scale as physicians/hospitals national fee scale. If your physician/hospital is not contracted with your insurance (which guarantees bringing business to your physician/hospital)then you will be responsible for the difference. If your physician/hospital is contracted, they will pay an allowable amount and the physician/hospital has to write off the balance less any copays or deductibles. If they accept the Reas & Cust amt from you as payment in full, they actually could be charged by the state/feds for abuse of the system if they do any state or federal billing. Reason being...if they bill Medicare a specific amt and Medicare contracts with the medical provider to pay them their allowable amt and the provider has to write off the balance, but accepts a lessor amt from another patient who's insurance only paid a certain amount and the provider wrote off the balance for that patient, then the provider would be ripping off the state/feds and they could be in high water for that. So legally, they cannot accept the Reasonable & Cust amount from you, unless they accept hardship patients where you would fill out hardship forms and this would have to be filed on your chart in case they were audited by the state, and I don't know any physician/hospital who would do that with this surgery especially when they know the situation up front. Also they would have to extend that same courtesy to every patient. And if that were the case, there would be no reason to contract with insurance co's to begin with. It's the insurance game! Hope this helps shed some light.
   — Karla K.

February 18, 2003
What Karla stated is accurate, however, usually the UCR (usual, customary and reasonable) payment is more than is paid/approved by federal/state programs therefore it is the doctor's option to write off the balance even if they are not required to. Even with writing off the balance, the amount they receive from your insurance company is very likely a larger payment than they would get from medicare. As to whether they will, only they can decide. I would not count on it. Normally UCR is determined by the average of costs charge in that area, as costs do vary drastically across the USA. <p>I know that none of my providers for my surgery are in network. However, I was able to verify that the amount the surgeon bills is fully covered and almost 100% sure the hospital will be too, based on previous experience with their charges. I know the anesthesiologist charges higher per base unit than UCR and expect around $100-150 balance. If they decide to bill me for the balance I will have to pay it, but they may write it off since 99% will be covered by insurance. BTC does legally owe you an estimate of charges so you have an idea what to expect, especially if they are making you sign that you will cover whatever insurance doesn't.
   — zoedogcbr