{"id":1949,"date":"2016-12-05T16:24:22","date_gmt":"2016-12-05T21:24:22","guid":{"rendered":"https:\/\/singlecare.com\/blog\/?p=1949"},"modified":"2020-07-31T14:54:50","modified_gmt":"2020-07-31T18:54:50","slug":"healthcare-defined-ucr","status":"publish","type":"post","link":"https:\/\/www.singlecare.com\/blog\/healthcare-defined-ucr\/","title":{"rendered":"What is Usual, Customary & Reasonable (UCR)?"},"content":{"rendered":"

If you\u2019ve ever been surprised by a medical bill, you\u2019re not alone. Sometimes that surprise happens because your insurance company didn\u2019t cover some or all of what your doctor charged for a medical procedure because it didn\u2019t meet their \u201cUCR,\u201d or \u201cusual, customary, and reasonable\u201d rate.\u00a0\u00a0<\/span><\/p>\n

Insurance companies use the UCR method to decide how much they will pay for an out-of-network medical service based on what a majority of other doctors in a geographic area charge. If your doctor bills above the insurance company\u2019s UCR rate, they may not agree to cover it all, charging you a UCR fee to pay the rest.\u00a0\u00a0<\/span><\/p>\n

If you use an in-network provider, and you have a <\/span>managed care plan<\/span><\/a> like an HMO, PPO, or POS, you don\u2019t really have to worry about UCR fees. That\u2019s because those providers have already negotiated with your insurance company and agreed to accept the UCR rate as their full payment. Sometimes, though, you may need to use an out-of-network provider, or you may have an <\/span>indemnity plan<\/span><\/a> (which is rare). That\u2019s why it\u2019s good to know how UCR fees work and how to avoid them if you can.<\/span><\/p>\n

What does UCR stand for?<\/span><\/h2>\n

UCR stands for usual, customary, and reasonable, and it defines how insurance companies decide if what a medical provider charges for a procedure is equal to or less than the maximum amount they think should be charged.\u00a0<\/span><\/p>\n

Here is how insurance companies define the usual, customary, and reasonable criteria:\u00a0<\/span><\/p>\n

Usual: <\/b>A charge is considered usual if it matches what an individual medical provider typically has charged patients in the past for the same or similar procedures or services.\u00a0<\/span><\/p>\n

Customary: <\/b>A charge is customary if it\u2019s within a range of fees that most other medical providers in a geographic area charge for the same or similar procedures or services.<\/span><\/p>\n

Reasonable:<\/b> A charge is considered reasonable if it meets both the usual and customary criteria or if it\u2019s a special circumstance. That might include a rare or very difficult procedure.\u00a0<\/span><\/p>\n

What does Usual, Customary, and Reasonable mean?<\/span><\/h2>\n

How insurance companies come up with their UCR charges can be a bit of a mystery, but most set their UCR charges at the <\/span>80th percentile<\/span><\/a>. That means that 80% of the medical providers in a given area charged equal to or less than the insurance company\u2019s UCR rate.\u00a0<\/span><\/p>\n

Here\u2019s how it works when it comes to how much they cover. Let\u2019s say you tear your meniscus while jogging and you have surgery to repair it. You use an out-of-network surgeon who bills $6,000 for the procedure. But your insurance company\u2019s UCR charge for that procedure is $5,000. If your insurance company typically pays 80% of your medical expenses before you meet your <\/span>deductible<\/span><\/a>, they would cover 80% of your bill up to $5,000. They would not cover the $1,000 above their UCR rate, which means you may need to pay the $1,000 UCR fee, in addition to your 20% coinsurance of the $5,000 UCR rate.<\/span><\/p>\n

In many cases, insurance companies don\u2019t count the money you pay above a UCR rate toward your deductible or <\/span>out-of-pocket maximum<\/span><\/a>. This means, if you regularly use out-of-network doctors, you could wind up paying a hefty amount in medical bills.\u00a0<\/span><\/p>\n

The good news is that most insurance plans, such as HMOs or PPOs, come with a large\u00a0 network of providers, including doctors, hospitals, labs, and therapists. If you stay in that network, you won\u2019t pay a UCR fee.\u00a0<\/span><\/p>\n

Medicare has its own version of UCR rates known as <\/span>Medicare allowable charges<\/span><\/a>. Any provider who agrees to participate in Medicare also agrees to accept the Medicare allowable charge rate as their full payment from the insurer. But some doctors who are non-participating providers can turn around and bill you for the difference. To help prevent that from happening, ask doctors if they accept Medicare assignment, which means they won\u2019t ask you to pay the balance of a bill. You will, however, still have to pay your deductible and <\/span>coinsurance<\/span><\/a>.\u00a0<\/span><\/p>\n

Some Medigap, or Medicare supplemental plans, may also help pay for excess physicians charges.\u00a0<\/span><\/p>\n

What is considered a UCR fee?\u00a0<\/span><\/h2>\n

There aren\u2019t very many regulations that determine how insurance companies decide their usual, customary, and reasonable rates. Many use their own data to determine what local doctors are charging for procedures. Legally, though, insurance companies must tell you how they came up with a rate if you ask.\u00a0<\/span><\/p>\n

There are some basic rules, though, that insurance companies follow to decide if a charge is usual, customary, and reasonable. The charge is consistent with what the medical provider has charged in the past (usual), it fits the range that other area doctors are charging (customary), and it either meets both the usual and customary criteria or it\u2019s a special circumstance (reasonable). If the insurance company thinks your medical provider\u2019s charge doesn\u2019t meet that criteria, they will only agree to pay the UCR rate, and you could have to pay the rest, which is the UCR fee.\u00a0<\/span><\/p>\n

Can you avoid paying UCR fees?<\/span><\/h3>\n

The best way to avoid paying UCR fees is to use in-network providers. Sometimes, though, that\u2019s unavoidable. If you know in advance that you\u2019ll be using an <\/span>out-of-network provider<\/span><\/a>, ask the doctor how much they will bill for the procedure or service. Then ask your insurance company what their UCR charge is for that procedure. You may be able to get your doctor to agree to accept the insurance\u2019s UCR charge as payment in full.\u00a0<\/span><\/p>\n

You also may be able to get your insurance company to pay more than the UCR rate if the doctor writes a letter explaining why they had to charge more for a certain procedure. It\u2019s also possible your insurance company may agree to adjust your bill post-procedure if you can show that multiple other doctors in the area charge a similar amount to what your doctor billed.\u00a0<\/span><\/p>\n

Do UCR fees apply to prescription drugs?\u00a0<\/span><\/h3>\n

Fortunately, when it comes to prescription drugs, it\u2019s not common to have to worry about UCR fees. That\u2019s because the UCR charge for prescription drugs is the amount someone without insurance would pay for a drug. This is also referred to as the \u201ccash price.\u201d\u00a0<\/span><\/p>\n

The good news is that SingleCare can help you save on your prescriptions\u2014no matter your insurance status. We believe everyone should be able to afford their medications. Start searching for your drugs on <\/span>singlecare.com<\/span><\/a>. You could save up to 80%.<\/span><\/p>\n","protected":false},"excerpt":{"rendered":"

If you\u2019ve ever been surprised by a medical bill, you\u2019re not alone. Sometimes that surprise happens because your insurance company didn\u2019t cover some or all of what your doctor charged for a medical procedure because it didn\u2019t meet their \u201cUCR,\u201d or \u201cusual, customary, and reasonable\u201d rate.\u00a0\u00a0 Insurance companies use the UCR method to decide how […]<\/p>\n","protected":false},"author":15,"featured_media":11797,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"footnotes":""},"categories":[2],"tags":[608,15],"coauthors":[8861],"class_list":["post-1949","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-company","tag-health-insurance","tag-medicare","franchise-healthcare-defined","wpautop"],"acf":[],"yoast_head":"\nWhat is Usual, Customary, and Reasonable (UCR)?<\/title>\n<meta name=\"description\" content=\"UCR stands for usual, customary, and reasonable. 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