Question:
Reasonable and Customary? Who decides?

I have United Healthcare POS, and was told at the time that I was approved, that my sergeon was not in the network. The told me they would cover 80% and I'd be responsible for 20%. I thought that was cool, so I went for it. Now, 5 months later, they only want to cover about 10%, beceause they say that amount is 80% of what's "Reasonable and Customary". Apparently, they go by what other surgeons in my area charge for the same procedure. How can they determine this when no other doctor does the micro-pouch? I told them he's a specialist, and it's not like having my tonsils out, so how can they say WHAT"S Reasonable OR customary? My doctors office is sending an appeal letter, so I'll have to wait and see what happens. Has anyone else experienced anything like this? HELP!!    — Danielle G. (posted on February 15, 2001)

February 15, 2001
I;ve experienced this with other medical needs. Its your insurance company, trying to save money. Sometimes they do this as a matter of course, hoping that you'll fork over the extra money. Let your surgeon help on this one -- it is in their interest to help you and any future patients with the same insurance. Don't buckle -- stay on them!
   — Cindy H.

September 3, 2002
I also have Untied Health Care. Same problem. No way I can afford to pay what is remaining. Let me know what happens.
   — Patricia H.