ISO: A Health Insurance Term

[Jinx]

I am hoping a SDoper in the industry (ideally) would know the term for this: I am aware insurance companies strike deals all the time with what they'll allow different health providers to charge them for different procedures. If these rates are acceptable to the healthcare provider (among other terms and conditions), said healthcare provider will agree to accept their insurance plan(s). Does anyone know the term for such a pre-agreed upon rate? Also, on the flip side, is there a term for the rate charged to someone with no insurance?

This is akin to how a hotel has a tiered billing schedule, and I've just been charged the "rack rate" vs. the driving club rate!

[MsRobyn]

Well, as a general practice, providers have to bill the same amount, whether it goes to an insurance company on a claim form or a bill straight to the patient.

I just found an old explanation of benefits. Tricare, my insurance company, calls the amount it has agreed to cover the "allowed amount." Other companies may use different terminology; ISTR another company called it a "provider allowance". There really isn't an industry standard term for it, at least not one that I'm aware of.

When I was in billing, we just called the full amount billed the "cash price" because the only people who would have to pay it are uninsured, or whose insurance won't cover the procedure but they choose to have it done anyway. Again, others may use a different expression, but it's the same thing.

[regginbrow]

The closest terms would probably be 'billed' and 'allowed' amounts for the non-discounted and discounted rates, respectively. I don't think this is really what you're looking for, though. The provider submits the billed amount to the insurance company, which is theoretically the same rate no matter the insurance status of the paitent, and the insurer reduces that rate down to the pre-agreed upon contracted rate, aka the allowed amount.

Possibly just 'contracted rates' would be better for you.

[doreen]

I've seen it referred to as "negotiated rate"