Re: UHC Out-of-network provider

[Guest guest]

Sumesh

You cannot gather usable data from everyone on this listserv. Usual, Reasonable

and Customary is determined by all LIKE providers in a geographic region. Your

charges are not evaluated with charges by PT and OT providers in Iowa,

California, etc. They are thrown into a computer with PT's and OT's in your

metropolitan area. Depending on the insurer, your geographic region might be

Metro Baltimore, it might be Baltimore and DC or it could be the entire state of

land. It really depends on what region the insurer chooses to use. I

expect that as large and populous as Baltimore is, you are probably being

benchmarked against therapists in the metropolitan area.

In Iowa, most insurance companies use a 3 or 4 digit zip code region (so Cedar

Rapids/my town might be benchmarked against other therapists in Eastern Iowa).

However, BCBS of Iowa used to use the entire state as their zip code region. At

some point they quit URC and just went to the Medicare Fee Schedule (plus/minus

a few cents per procedure code).

Not sure if this will help you, but if you (or anyone else reading this) would

like clarification, please feel free to contact me off the listserv.

Jim Hall, CPA <///><

Rehab Management Services, LLC

Cedar Rapids, IA

319/892-0142

Visit our Website at:

www.rehabmgmt.com

UHC Out-of-network provider

For those of you who are non-participating providers with United Health Care

(UHC) what is your usual and customary reimbursement from UHC? It is

approximately $160/visit for me in Baltimore, MD.

Sumesh , PT

Baltimore, MD

[Guest guest]

Sumesh

You cannot gather usable data from everyone on this listserv. Usual, Reasonable

and Customary is determined by all LIKE providers in a geographic region. Your

charges are not evaluated with charges by PT and OT providers in Iowa,

California, etc. They are thrown into a computer with PT's and OT's in your

metropolitan area. Depending on the insurer, your geographic region might be

Metro Baltimore, it might be Baltimore and DC or it could be the entire state of

land. It really depends on what region the insurer chooses to use. I

expect that as large and populous as Baltimore is, you are probably being

benchmarked against therapists in the metropolitan area.

In Iowa, most insurance companies use a 3 or 4 digit zip code region (so Cedar

Rapids/my town might be benchmarked against other therapists in Eastern Iowa).

However, BCBS of Iowa used to use the entire state as their zip code region. At

some point they quit URC and just went to the Medicare Fee Schedule (plus/minus

a few cents per procedure code).

Not sure if this will help you, but if you (or anyone else reading this) would

like clarification, please feel free to contact me off the listserv.

Jim Hall, CPA <///><

Rehab Management Services, LLC

Cedar Rapids, IA

319/892-0142

Visit our Website at:

www.rehabmgmt.com

UHC Out-of-network provider

For those of you who are non-participating providers with United Health Care

(UHC) what is your usual and customary reimbursement from UHC? It is

approximately $160/visit for me in Baltimore, MD.

Sumesh , PT

Baltimore, MD

[Guest guest]

Sumesh

You cannot gather usable data from everyone on this listserv. Usual, Reasonable

and Customary is determined by all LIKE providers in a geographic region. Your

charges are not evaluated with charges by PT and OT providers in Iowa,

California, etc. They are thrown into a computer with PT's and OT's in your

metropolitan area. Depending on the insurer, your geographic region might be

Metro Baltimore, it might be Baltimore and DC or it could be the entire state of

land. It really depends on what region the insurer chooses to use. I

expect that as large and populous as Baltimore is, you are probably being

benchmarked against therapists in the metropolitan area.

In Iowa, most insurance companies use a 3 or 4 digit zip code region (so Cedar

Rapids/my town might be benchmarked against other therapists in Eastern Iowa).

However, BCBS of Iowa used to use the entire state as their zip code region. At

some point they quit URC and just went to the Medicare Fee Schedule (plus/minus

a few cents per procedure code).

Not sure if this will help you, but if you (or anyone else reading this) would

like clarification, please feel free to contact me off the listserv.

Jim Hall, CPA <///><

Rehab Management Services, LLC

Cedar Rapids, IA

319/892-0142

Visit our Website at:

www.rehabmgmt.com

UHC Out-of-network provider

For those of you who are non-participating providers with United Health Care

(UHC) what is your usual and customary reimbursement from UHC? It is

approximately $160/visit for me in Baltimore, MD.

Sumesh , PT

Baltimore, MD

[Guest guest]

Exactly what Jim says but with another twist. Before I became a therapist I

lived in Chicago and sold group insurance and pension plans to large companies

(more than 200 employees) and the employers would buy the policies with

different usual and customary 'set points' Let's say that U & C is $50 for

therapeutic exercise. Company ABC may purchase a policy that pays at 90% of

U & C ($45) and another company may purchase a policy that pays at 70% U & C ($35).

Good luck finding the true level of U & C, most insurers guard that as proprietary

information.

Matt Capo, PT

Accelerated Physical Therapy and Occupational Health, Inc.

Bay St. Louis and Diamondhead, Mississippi

UHC Out-of-network provider

For those of you who are non-participating providers with United Health Care

(UHC) what is your usual and customary reimbursement from UHC? It is

approximately $160/visit for me in Baltimore, MD.

Sumesh , PT

Baltimore, MD

[Guest guest]

Exactly what Jim says but with another twist. Before I became a therapist I

lived in Chicago and sold group insurance and pension plans to large companies

(more than 200 employees) and the employers would buy the policies with

different usual and customary 'set points' Let's say that U & C is $50 for

therapeutic exercise. Company ABC may purchase a policy that pays at 90% of

U & C ($45) and another company may purchase a policy that pays at 70% U & C ($35).

Good luck finding the true level of U & C, most insurers guard that as proprietary

information.

Matt Capo, PT

Accelerated Physical Therapy and Occupational Health, Inc.

Bay St. Louis and Diamondhead, Mississippi

UHC Out-of-network provider

For those of you who are non-participating providers with United Health Care

(UHC) what is your usual and customary reimbursement from UHC? It is

approximately $160/visit for me in Baltimore, MD.

Sumesh , PT

Baltimore, MD

[Guest guest]

Exactly what Jim says but with another twist. Before I became a therapist I

lived in Chicago and sold group insurance and pension plans to large companies

(more than 200 employees) and the employers would buy the policies with

different usual and customary 'set points' Let's say that U & C is $50 for

therapeutic exercise. Company ABC may purchase a policy that pays at 90% of

U & C ($45) and another company may purchase a policy that pays at 70% U & C ($35).

Good luck finding the true level of U & C, most insurers guard that as proprietary

information.

Matt Capo, PT

Accelerated Physical Therapy and Occupational Health, Inc.

Bay St. Louis and Diamondhead, Mississippi

UHC Out-of-network provider

For those of you who are non-participating providers with United Health Care

(UHC) what is your usual and customary reimbursement from UHC? It is

approximately $160/visit for me in Baltimore, MD.

Sumesh , PT

Baltimore, MD

[Guest guest]

Matt,

The truth is that " reasonable and customary " is, at least at times, a myth.

Many years ago, after the birth of our first child, we found our insurer would

pay only a fraction of the bill based on their R & C. I pursued the issue of how

R & C was established (both geographically and statistically) which took many

phone calls and many unproductive conversations before finding someone who was

willing to give me that facts. For that particular insurance, I found that they

based their R & C on a county basis in NJ and on the mean of the charges. I

subsequently called all two dozen ob/gyn practitioners that I could find in the

county and found that ALL of them charged significantly ABOVE R & C, thereby

rendering the insurance company's so-called R & C a pure fabrication. I called

back the insurance company and with a little leveraging involving threat of

legal action and the involvement of the NJ insurance commission (which actually

had some teeth as compared to Michigan's useless commission), I got paid the

full amount. The problem with so many of these issues is that collectively,

physical therapists are willing to bend over and say " Please sir, may I have

another " , and that's exactly what we get.

, PT, OCS

Marquette, MI

UHC Out-of-network provider

For those of you who are non-participating providers with United Health Care

(UHC) what is your usual and customary reimbursement from UHC? It is

approximately $160/visit for me in Baltimore, MD.

Sumesh , PT

Baltimore, MD

[Guest guest]

I have encouraged several patients in the Bethesda, land region who were

told that my charges were above usual and customary to call 20-30 PT practices

in the area to see what their charges are. ABout 25 percent were cheaper, most

were in the same range and about 25% were much higher. Interestingly, the more

expense practices were either hospital- or physician-owned. The concept of R & C

is pure nonsense. A few of these patients managed to get paid after presenting

the data; others did not get anywhere.

Jan

Jan Dommerholt, PT, DPT, MPS, DAAPM

Bethesda Physiocare®, Inc.

7830 Old town Road, Suite C-15

Bethesda, MD 20814-2440

United States

+ (voice)

+ (fax)

dommerholt@...

www.bethesdaphysiocare.com

Anne Arundel Physiocare®

127 Lubrano Dr, Suite L-3

polis, MD 21401-7322

+ (voice)

Myopain Seminars, LLC

+ (voice)

+ (fax)

www.myopainseminars.com

dommerholt@...

http://www.linkedin.com/in/jandommerholt

> IMPORTANT NOTICE

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it is addressed and may contain information that is privileged, confidential and

exempt from disclosure under applicable law. If you have received this message

in error, you are hereby notified that we do not consent to any reading,

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> Bethesda Physiocare®

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[Guest guest]

I totally agree that U & C fees are arbitrary and have little, if any, basis in

true data. When I was selling group insurance and a potential client would ask

how we derived U & C I would always say, " I will have to have actuarial call you

on that " .

A simple google search will yield many cases of the AMA bringing suit against

Aetna, UnitedHealtcare, etc for manipulation of U & C fees. I really don't know

if the APTA has ever done the same.

Matt Capo, PT

Accelerated Physical Therapy and Occupational Health, Inc.

Bay St. Louis and Diamondhead, Mississippi

Re: UHC Out-of-network provider

I have encouraged several patients in the Bethesda, land region who were

told that my charges were above usual and customary to call 20-30 PT practices

in the area to see what their charges are. ABout 25 percent were cheaper, most

were in the same range and about 25% were much higher. Interestingly, the more

expense practices were either hospital- or physician-owned. The concept of R & C

is pure nonsense. A few of these patients managed to get paid after presenting

the data; others did not get anywhere.

Jan

Jan Dommerholt, PT, DPT, MPS, DAAPM

Bethesda Physiocare®, Inc.

7830 Old town Road, Suite C-15

Bethesda, MD 20814-2440

United States

+ (voice)

+ (fax)

dommerholt@...

www.bethesdaphysiocare.com

Anne Arundel Physiocare®

127 Lubrano Dr, Suite L-3

polis, MD 21401-7322

+ (voice)

Myopain Seminars, LLC

+ (voice)

+ (fax)

www.myopainseminars.com

dommerholt@...

http://www.linkedin.com/in/jandommerholt

> IMPORTANT NOTICE

> This message is intended only for the use of the individual or entity to which

it is addressed and may contain information that is privileged, confidential and

exempt from disclosure under applicable law. If you have received this message

in error, you are hereby notified that we do not consent to any reading,

dissemination, distribution, or copying of this message. If you have received

this communication in error, please accept our apologies. notify the sender

immediately and destroy the transmitted information.

>

> Thank you.

>

> Bethesda Physiocare®

>