Usual, Customary and Reasonable Fees
Usual, customary and reasonable fees refer to costs for health care that aren't reimbursed by insurance companies and that a person who holds a health insurance policy should cover himself. They may vary from service to service and from state to state, in which medical care is being provided.
Usual, Customary and Reasonable Fees explained
For a charge to be considered UCR it should meet the following requirements:
- It should be collected for a medical specialist to pay for medical treatment and care.
- The price doesn’t exceed the actual cost of carrying out medical tests in other medical centers in this area.
- The fee is imposed on the service that is considered essential to preserving life.
Monitoring of the usual, customary and reasonable fees is conducted by the insurer, which takes into consideration other similar services offered in the geographic area and decides whether they are needed. If the center overcharges for the appointment, the policyholder will have to cover the difference between the fee collected to pay for a service and the amount paid by the insurance company.
A citizen can check the policy to find out how much of the therapy the health insurance covers and what is deemed to be usual, customary and reasonable fees. For instance, health insurance plans may include coverage for “out-of-network” and “network” providers. If the medical specialist has no contract with the health plan, he doesn’t participate in the plan's network and the policyholder may be even charged the full price.
A lot of patients don’t think beforehand of the cost of a doctor's visit and a bill from the provider can be very unexpected for them. To prevent it, a policyholder should make sure that a doctor is included in the list of the doctors that a plan arranges a formal agreement to provide medical care, ask the medical specialist about the cost of the medical treatment, or contact the insurance company to find out more about the usual, customary and reasonable fees.
Medicare program
Medicare usual, customary and reasonable fees are not monitored by the federal agencies. However, Medicare has a complete listing of fees used to pay doctors or other providers. The provider or supplier is required to accept Medicare-approved charge as full payment for covered treatment.
If the billed charge is higher than the allowed amount, in some cases, fees may not be charged for a patient. But he should make sure that providers and suppliers are enrolled in the Medicare program.
