How can a health insurance company allow providers to charge unreasonable rate?

UPDATED: Sep 30, 2022

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How can a health insurance company allow providers to charge unreasonable rate?

My husband has health insurance through Medical Mutual of Ohio. We have a
6000 deductible. Because my husband has been ill, we are rapidly approaching
our deductible. 5,842 A physical therapy charge for 30 minutes was 395.
A neurologist charge was 303. Now it gets a little more interesting. Our most
recent visit to a spine specialist cost 18.00. Some of the charges seem
unreasonable, while this new charge is quite low as we approach our deductible.
These practices do not seem to be in good faith. Are there watchdogs for these
medical charges and the insurance companies part in this?

Asked on May 22, 2016 under Insurance Law, Ohio


SJZ, Member, New York Bar / FreeAdvice Contributing Attorney

Answered 6 years ago | Contributor

The health insurer does not "allow" the provider to charge unreasonable rates: the insurer does not control what providers chargers (the providers do not work for it or otherwise are under its control; providing payment from insurance does not make you the "boss" of the providers or vendors who get the payment), but rather simply pays some or all of their charges (or reimburses you for your payments, as applicable), according to the terms of the policy. The insured (i.e. you) has to be a smart shopper and self-interested consumer and, in non-emergency situations at least, ask doctors and clinics about what they charge *before* making the appointment; the insurer does not watch out for your costs for you.

IMPORTANT NOTICE: The Answer(s) provided above are for general information only. The attorney providing the answer was not serving as the attorney for the person submitting the question or in any attorney-client relationship with such person. Laws may vary from state to state, and sometimes change. Tiny variations in the facts, or a fact not set forth in a question, often can change a legal outcome or an attorney's conclusion. Although has verified the attorney was admitted to practice law in at least one jurisdiction, he or she may not be authorized to practice law in the jurisdiction referred to in the question, nor is he or she necessarily experienced in the area of the law involved. Unlike the information in the Answer(s) above, upon which you should NOT rely, for personal advice you can rely upon we suggest you retain an attorney to represent you.

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