Q. Why shouldn’t we use usual and customary payments as the standard for OON benefits? | Physicians For Fair Coverage

A: A usual and customary rate is a euphemism for a discounted, contracted payment to in-network providers, who usually get considerations of value, such as volume referrals or faster payment, in exchange for the discount. OON providers do not receive such considerations; in fact, plans routinely try to dissuade patients from using OON providers. Furthermore, there are no readily available and validated databases of contracted payment rates, as these are protected by non-disclosure provisions in-network contracts. This would be a non-transparent, black-box standard. 

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