Dealing with ZIP Code and Other Errors with UCR Claims

Part 2, Chapter 4: Traditional Individual and Group Plans, Doctors' Bills Page 9

Continued from Previous Page

By error, the insurance company had used the address of the office farthest from the hospital as the basis for the UCR analysis, even though the original exam had taken place at the office nearest the hospital and the procedure had taken place at the hospital itself. I asked a supervisor at the insurance company to review the UCR, using either the hospital address (where the treatment had occurred) or the address of the doctor's office nearest the hospital (where the patient had originally been examined). Both were in the same ZIP code. When the analysis was redone, the amount of reimbursement was increased by more than $300, leaving a balance of less than $100.

If the ZIP code that the insurer used to determine the UCR is correct in a particular case, the next step is to talk with your medical provider about how his fees compare to those of other local providers, and to check with the local medical society to try to determine a range of bills for the procedure from other providers in the area. If your doctor's fee is similar to, or lower than, the fees of other providers in the area for the same procedure, you can send in a claim appeal asking the insurer to review the UCR analysis. Include the information provided by your doctor and the local medical society with your appeal. That may be sufficient to persuade your insurer to reconsider the UCR determination.

In some cases, that claim appeal may lead to a successful resolution of the problem. If it does not, the next step is to write to your county or state medical society or to your state Department of Insurance and ask for their help. (See Chapter 3 for more information on claim appeals.)

Continued on Next Page