Usual, Customary and Reasonable Fees

Everyone gather ‘round, because it’s time for another episode of How Much Will We Pay?, the show that attempts to guess how much our insurance company is going to bill us for our healthcare services.

It’s always a bit of a mystery, isn’t it? Sure, we sometimes know whether certain things are covered or not, but the actual dollar amount that’s charged versus what our insurance will cover versus what we’ll get billed for? That’s anyone’s guess.

Or...is it? As it turns out, there is a method to the medical billing madness, and it’s called “usual, customary, and reasonable fees,” or “UCR fees,” if we’re the cool kids. Which we are. The UCR philosophy is applied to consultation fees, procedure fees, prescription costs, equipment costs...all of it. “UCR fees” are how much we’re going to be asked to pay after our insurance covers what it will cover, and they’re determined using this incredibly complex calculation that isn’t vague at all: “How much are other doctors in the area charging for this same service when it’s necessary for the patient?”

That’s it. That’s how UCR fees are determined. So if every oral surgeon in the Pittsburgh metro area is charging $1,200 for necessary root canals and we go to a dentist who’s charging $2,500 for the same procedure, there’s a good chance our insurance isn’t going to cover the whole $2,500. But they’ll probably cover $1,200, because $1,200 is usual (other dentists charge this amount every day all over town), it’s customary (very few dentists dare deviate from the accepted root canal cost), and it’s reasonable (it’s the going rate for a root canal, and it would be hard to find a decent dentist who would do one cheaper).