Risky Business: Using out-of-network providers
When choosing a health care provider, your best choice is a provider from the First Choice Health network. Here's why:
First Choice is a preferred provider organization (PPO), which means providers have agreed to discounted rates for their services. When you use a preferred provider, you're able to take advantage of that negotiated rate. More important, you're guaranteed that your out-of-pocket share of a covered service will not exceed 10% of the billed amount. After satisfying your annual out-of-pocket maximum ($2,300), covered services from preferred providers are paid at 100%.
The scenario looks much different when you use out-of-network providers. First, you don't have the assurance of a negotiated rate for a covered service. Non-preferred providers can set their fees as high as they want. This is important to remember, because the Carpenters Health and Security Plan limits the reimbursement amount to the “usual, customary and reasonable charge” for the covered service.
Providers and the Carpenters health plan are not always in agreement about what the usual, customary and reasonable charge should be. Any gap between the amount charged by the out-of-network provider and the amount paid by the health plan is the patient's responsibility.
When you elect to receive care from out-of-network providers, you take on the risk of substantially higher out-of-pocket expenses. There is no guarantee that your out-of-pocket share will not exceed 10% of the cost, or that it will be paid at 100% if you satisfy the annual out-of-pocket maximum. As a recent example, consider the member who chose to have surgery at an out-of-network provider and was billed more than $37,000 for charges that exceeded the “usual, customary and reasonable” allowance.
To prevent this from happening to you, we suggest that you first receive a quote from your provider prior to the procedure. Then, call the Trust Office for an estimate of the allowed payment amount. Providers do not have access to our allowed payment schedule, so it is always better to check with the Trust Office first.