A Fee for Service plan is one of the many types of health plans that are offered by health insurance carriers. A Fee for Service plan is the most simplistic of all of the plan types since standard Fee for Service plans are not considered managed care plans.
The patient is seen by any doctor they choose. There are no provider directories to look through in order to locate an in network provider.
Most health carriers will not just pay off the billed amount, the claim will pass through some type of pricing data. Usually for Fee for Service plans, that data is Usual, Customary and Reasonable (UCR).
Let’s look at an example.
Dr. Smith performs an office visit for $200.00 and a chest x-ray for $100.00 and he bills the claim to the insurance company for his normal rate of $300.00. In spite of the fact that no in network arrangement exists, the health carrier will still seek ways to price this claim. After being priced, the health carrier determines that $150.00 for the office visit and $50.00 for the x-ray is accepted. The plan allows $200.00 instead of the billed amount of $300.00. The patient is responsible for the difference.
Since Fee for Service plans were written so that the plan participants would share in the cost of healthcare, members are required to pay the deductible and co-insurance amounts.
Let's look at another example of how a payment would be made on a standard fee for service plan.
James has a Fee for Service plan. He becomes ill
and is seen in the emergency room. His total bill is $3500.00.
Carrier pays $2720.00
Patient pays $780.00 ($100.00 deductible + $680.00)
Standard Fee for Service plans are the most expensive plans to purchase because they do not have the managed care component that helps to control costs; contracted providers that accept reduced rates, more front end controls and requirements, etc.
Note: For the
purpose of this article, Standard Fee for Service means that the Fee for
Service plan is not part of a managed care plan.
Advantages to Members Participating in FFS Plans
Disadvantages to Members Participating in FFS Plans
Advantages to Providers Participating in FFS Plans
Disadvantages to Providers Participating in FFS Plans