[California] Amount allowed (customary and appropriate) is different for in-network v. out-of-network

Background: I filed a complaint with my PPO healthcare insurer because I felt that their "amount allowed" for an out of network doctor was below market-rates. While that is pending, I received an EOB this month in which the SAME medical provider in the same month for the same code was reimbursed to me as "in-network".

Amount allowed (in-network): $207.53 on $225 amt. billed Amount allowed (out-of-network): $89.10 on $225 amt. billed

Question: It seems like this proves my point that their amount allowed for my out of network claims is below market when in fact they are allowing $207 on in-network doctors. In this particular case, there are fewer variables. Same procedure code, same doctor, same month.

I understand that out-of-network is usually more expensive out of pocket but when the insurance company claims an allowable amount is lower of rate the same procedure … that sounds illegal to me.

Is this allowed? Does it bolster my argument for upping their 'allowable amount' for my out of network doctors' visits?

tl;dr. CA insurance co. is claiming two different 'amount allowed"'s for in-network and out-of-network services in the same month, same doctor.

submitted by /u/dogballs8
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