Learning About UCR Reimbursements from Health Insurance Companies

Part 2, Chapter 4: Traditional Individual and Group Plans, Doctors' Bills Page 11

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In this case, if the insurer sets reimbursement to the fiftieth percentile, the maximum amount that the insurer would consider for the appendectomy would be $1,000. If the insurance policy provides reimbursement of major medical bills at the 80% rate (an 80/20 plan), and the surgeon's bill is $1,600, the actual reimbursement would be $800 (80% of $1,000), leaving a balance bill of $800.

However, if the insurer sets reimbursement to the eightieth percentile in this case, the company would consider a maximum of $1,300. In that case, the actual reimbursement would be $1,040 (80% of $1,300), leaving a balance bill of $560. If the insurer sets reimbursement to the ninetieth percentile, the insurer would consider a maximum of $1,650. That would be reduced to $1,600, the amount of the bill. In that case, the actual reimbursement would be $1,280 (80% of $1,600). That would leave a balance bill of only $320. Thus, the percentile that's used by an insurer in determining the UCR may significantly affect the amount of reimbursement (See Table 11).

The percentile system may not always be discussed in detail in health insurance policy booklets. You may need to check with your insurer to determine the specific percentile that is used by the company.

Table 11: Hypothetical Example of Charges and Percentiles for an Appendectomy

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