Patient Financial Responsibility
Patient Responsibilities
As a patient, it is in your best interest to know and understand your insurance plan benefits and your responsibility for any deductibles, co-insurance, or co-payment amounts prior to any visit. Not all services are covered in all insurance contracts. If your insurance plan does not cover a service or procedure, you are responsible for payment of these charges.
To find out what your insurance plan covers and what your financial obligation may be, call the customer service or member services department of your insurance company (the phone numbers are on your insurance card). Your employer's human resources department may also be a source of information and assistance.
Patients with insurance questions or concerns may also contact the University of Chicago's Office of Managed Care at (773) 834-4730.
While you may have insurance coverage to pay your medical bills, you are ultimately responsible for all charges. You are responsible to notify us of your insurance and to provide the necessary information about your insurance plan; therefore, please have your current insurance card with you at all times, as well as a photo ID such as a driver's license, military ID, or government issued ID.
Make sure that both your physician and hospital are listed as a participating provider by your insurance company. It is possible that only the physician or only the hospital participates with your insurance plan. If not listed, contact your plan's customer service department or the University of Chicago's Office of Managed Care at (773) 834-4730 to verify.
It is your responsibility to know your insurance company's patient responsibilities and procedures. If proper procedures are not followed, you may be liable for full payment of the bill. If your insurance company requires a referral and/or prior authorization, contact your primary care physician prior to seeing a specialist.
A referral may be required to see a specialist, while a prior authorization is usually required for laboratory tests or medical procedures.
If your insurance company requires a referral and/or prior authorization and you do not have one, you may not be seen for your scheduled appointment, or you will be responsible for full payment of your bill at the time of service.
If your specialist requires more visits than your insurer approves or if the referral has expired, you must contact your primary care physician for another referral and/or prior authorization.
Benefit and coverage rules and policies differ among insurers and even between different plans of the same insurer. If you go to an out-of-network provider, your insurance company may only pay a percentage of the rates they determine are usual, customary, and reasonable (UCR) rates. You will be responsible for the amount of charges over the insurer's UCR plus your usual deductible and co-payment. Your insurance company can assist you in finding an in-network provider to limit the amount of money you will have to pay for care.
Usual, Customary, and Reasonable Rates
Most insurance companies will pay only what is called a “usual, customary, and reasonable” (UCR) rate for hospital and physician services that are provided by an out-of-network physician or hospital.
Each insurance company determines its own UCR rates for different medical services.
Usually the UCR rate set by an insurance company is considerably lower than the hospital's or physician's charge for services. Payment by the insurance company is often a percentage of the UCR rate for a given procedure/service. See examples
If your insurance company pays based on UCR, you are then responsible to pay the difference between the UCR payment made by the insurance company and the charge for the service billed by the hospital or physician. This is in addition to the deductible and co-payment/co-insurance that you must pay according to your insurance plan.
Please note that most health insurance plans do not apply the portion of charges above the UCR towards your deductible or annual out-of-pocket maximum.
Your insurance company is required by Illinois law to warn you in writing that you may owe more money by using a non-participating provider (out-of-network) than if you were to seek care at a participating provider. The following statement should be in your health insurance policy:
"Warning: Limited benefits will be paid when non-participating providers are used. You should be aware that when you elect to utilize the services of a non-participating provider for a covered service in non-emergency situations, benefit payments to such nonparticipating providers are not based upon the amount billed. The basis of your benefit payment will be determined according to your policy's fee schedule, usual and customary charge (which is determined by comparing charges for similar services adjusted for the geographical area where the services are performed), or other method as defined by the policy. You can expect to pay more than the coinsurance amount defined in the policy after the plan has paid its required portion. Nonparticipating providers may bill members for any amount up to the billed charge after the plan has paid its portion of the bill …"
If you cannot find UCR information in your insurance policy, call your insurance company and/or contact your employer to determine whether your insurance company uses UCR.
Examples of Usual, Customary, and Reasonable Rates
Example One
Your inpatient hospital bill at an out-of-network hospital was $10,000. Your insurance company determines that the UCR rate is $7,000. You have not yet met your annual $500 deductible, so you must first pay $500 of the UCR before your insurance company will pay anything. This leaves $6,500 to be paid by the insurance company for a total paid of $7,000; but since the hospital's charges are $10,000, you must also pay an additional $3,000 for a total payment responsibility of $3,500.
Example Two
You receive services from an out-of-network hospital and your insurance reimburses 70% of the UCR rate. The hospital bills $2,500, but the UCR rate is $2,000. The plan would pay 70% of $2,000, or $1,400. Your coinsurance is 30%, which is $600. This $600 would apply to your annual out-of-pocket maximum. However, since your health plan determines that the UCR rate is $2,000, you would also be responsible for the rest of the bill, which is $500. So you would have to pay a total of $1,100 but only $600 would apply to your annual out-of-pocket maximum.
Example Three
You were an inpatient at an out-of-network hospital and your total bill was $15,000. Your insurance company usually pays 80% of the UCR, however you have already met your annual $2,000 out-of-pocket maximum, so the insurance company will pay 100% of UCR ($10,000). Even though you met your out-of-pocket maximum, you are still responsible for the difference between the hospital's charges and the insurance company's UCR, which is $5,000.
