112. How does an approved maximum charge affect payment for treatment?

Approved Maximum Charge

This is the maximum fee approved by your insurance company for a specific service. It has no relation to reasonable charges, but is a way for the company to cap their liability for services.

You can choose a provider who charges any fee, but you will be responsible for more of the costs if you choose a more expensive provider.

For example, suppose your MC company has an approved maximum charge of $50 per session for Individual Psychotherapy. But, most psychologists in your area charge between $80 and $100. In this case, the MC company will only consider $50 out of each charge when computing their reimbursement rate. So, if the fee is $90, and they reimburse at 70 percent, they will pay 70 percent of $50, or $35, and you will be responsible for the balance, or $55. You can see how this reduces the actual percentage that the insurance company will pay. In this case, they actually paid only 39 percent, not 70 percent.

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