Question: What does "customary and reasonable" cost really mean?
I had surgery done, and the insurance company says that the doctor’s bill is higher than the “customary and reasonable” cost of the surgical procedure. The insurer refuses to pay the full claim. What can I do?
Answer:
Insurance companies often pay claims based on the average cost of the procedure in your area. This is referred to as the “customary and reasonable” cost. Customary and reasonable cost varies from region to region and state to state.
You can ask your insurance company how they arrived at the customary and reasonable cost for your procedure, ask other medical providers how much they charge for your procedure, and/or ask your doctor if your procedure differed from the norm in any way. For example, your doctor may have charged more because you required more attention than the average patient or experienced complications during the procedure.
