Which phrase refers to the fees charged by a healthcare professional?

• A. Deductible
• B. Usual, customary, and reasonable expenses
• C. Coinsurance
• D. Out-of-pocket maximum

Answer: (B)

The concept being tested is how insurance terms describe the fees a provider charges for a service. The phrase that fits this description is Usual, customary, and reasonable expenses.

Usual refers to the provider’s typical charge for a given service. Customary describes the range of charges commonly billed in a geographic area for the same service. Reasonable accounts for exceptions when a charge is higher due to special circumstances but not excessive. Together, this trio is used by many plans to determine how much the insurer will reimburse. Often the payment is based on the lower of the provider’s billed amount and the customary/allowed amount in that area, with the patient potentially covering any difference if the provider is out of network or the charge exceeds what the plan considers reasonable.

The other terms describe different concepts: a deductible is what you pay before coverage starts; coinsurance is the percentage you pay after meeting the deductible; the out-of-pocket maximum is the cap on your annual expenses.