Reasonable and Customary Fees Applied to Paramedical Services
Consistent with industry standards, Industrial Alliance applies reasonable and customary limits to paramedical services. Paramedical services refer to health treatments such as; massage therapy, physiotherapy, acupuncture, speech therapy, chiropractic care, etc. We review reasonable and customary limits on a continual basis and make changes periodically to ensure that our allowed amounts are representative of the current standard fees in the health care environment. Our latest review has resulted in new reasonable and customary limits and these will take effect on January 1, 2014.
What are reasonable and customary fees?
Reasonable and customary fees refer to a range of fees most practitioners normally charge for paramedical services or treatments. A fee is considered reasonable and customary if it matches the average cost of that service within a geographic area.
How are these limits established?
Industrial Alliance, along with other health benefit providers, uses these fees to determine maximum eligible amounts for paramedical services and supplies covered by your plan based on:
- Published fee schedules from provincial/territorial associations.
- Standard reasonable and customary fees for provincial/territorial associations without published fee schedules.
- Surveyed responses from practitioners within specific provinces/territories when information from associations is not available.
- Analysis of past claims.
How do these limits affect the payment of claims?
Limits will be applied to claims for paramedical services if the provider charges more than the reasonable and customary limit. Plan members will be responsible for paying the difference. Limits are also subject to any deductibles and plan reimbursement percentages according to plan specifications. Patients who require non-standard treatments with fees that exceed the reasonable and customary limits are reviewed on an individual basis.
For paramedical fees to be considered eligible for coverage under your group benefits plan, Industrial Alliance requires that the paramedical practitioner be licensed by the appropriate provincial or federal organization to practice their profession in accordance with the rules of his profession.
As of January 1, 2014, you may refer to the list of reasonable and customary fees in the Document Centre under Guides and Resources via our secured website CyberClient. For further information regarding your coverage on reasonable and customary fees or paramedical services, please refer to your group benefits booklet or contact our customer service department at 1 877 422-6487.
If you have any questions or concerns regarding this matter, please contact your benefits advisor or your Industrial Alliance group account executive.