Legal Question in Insurance Law in Illinois

Re: usual and customary charges vs. medicare rates

You're in a tough situation and, unfortunately, one that is all-too-common. Indeed, I personally have had (and will again soon have) a similarly bad time.

From a practical standpoint, you must ask yourself two principal questions. First, how much money is at stake? Was this some sort of, say, bone marrow transplant, where the difference between the "usual & customary" and the amount actually charged is significant? In other words, are the amounts at issue significant enough to warrant litigation? Second, is your plan offered through your employment? In other words, is the plan governed by ERISA, which has certain limitations on causes of action?

Setting these issues aside, I have been toying around with a theory that says that the hospital (or doctor) is simply charging too much, since it (or the doctor) often discounts certain of its charges to its "best" customers, i.e., those companies with whom it has contractual rates. If those companies make up a majority of the hospital's (or doctor's) billings, then that, in fact, is the "usual & customary" amount to be billed, not the amount that the hospital billed you.

If the amount at issue is significant to warrant litigation, you should see a lawyer. If, on the other hand, the amounts at issue are small, you might want to see if you can negotiate a smaller amount or make payments over time.

-- Kenneth J. Ashman; www.AshmanLawOffices.com

This communication is intended for general informational purposes only and is not intended to create an attorney-client relationship, which can only be accomplished under the policy of Ashman Law Offices, LLC by the execution of a formal retention agreement.