Usual, Customary, and Reasonable Flashcards

Questions and Answers

What does UCR stand for?

Usual, Customary, and Reasonable (correct)

Universal, Common, and Regular

Variable, Appropriate, and Statutory

None of the above

What is the difference between fee schedules and UCR fees?

Fee schedules are set rates for services, while UCR takes these rates a step further.

How are UCR rates set?

UCR rates are set by third-party payers based on historical data for a specific geographic area or medical specialty.

What does 'Usual' refer to in UCR?

Usual refers to the provider's practice. Signup and view all the answers

What does 'Customary' refer to in UCR?

Customary refers to the community. Signup and view all the answers

What does 'Reasonable' refer to in UCR?

Reasonable refers to the situation. Signup and view all the answers

Will the patient be billed the balance with UCR fees?

The balance may or may not be billed to the patient. Signup and view all the answers

What is the UCR amount based on?

What providers usually charge in a geographic area Signup and view all the answers

Match the following services with their corresponding UCR values in the Northwest Area:

Mid-level exam = $61.21 Detailed exam = $92.07 Comprehensive exam = $124.16 Total Abdominal Hysterectomy = $910.06 Signup and view all the answers

Study Notes

Usual, Customary, and Reasonable (UCR) Overview

UCR refers to the payment amount for medical services in a specific geographic area based on typical charges by local providers.
UCR amounts help determine the accepted payment amount from insurance companies to providers.
This reimbursement method extends from the fee schedule retrospective reimbursement system.

Fee Schedules vs. UCR Fees

Fee schedules consist of predetermined rates for specific medical services.
UCR fees expand on fee schedules by considering what providers typically charge within a community.

Setting UCR Rates

UCR rates are established by third-party payers using historical data relevant to particular geographic areas or medical specialties.
Claims are reimbursed at UCR rates rather than the billed amounts, depending on the established customary charges.

Definitions

Usual: Reflects the standard rates charged by the provider in their practice.
Customary: Represents the average charges seen within the community for specific services.
Reasonable: Describes the appropriateness of the fee based on the specific circumstances surrounding the medical service.

Sample Third-Party Payer UCR Fee Schedules

Code 99213 (Mid-level exam):
- Charge: $85
- UCR Amount: $61.21
Code 99214 (Detailed exam):
- Charge: $100
- UCR Amount: $92.07
Code 99215 (Comprehensive exam):
- Charge: $135
- UCR Amount: $124.16
Code 58150 (Total Abdominal Hysterectomy):
- Charge: $1400
- UCR Amount: $910.06

Patient Billing and UCR Fees

Patients may or may not be billed for the remaining balance after UCR fees are applied.
Factors influencing UCR-based billing include geographic location, urban versus rural distinctions, and medical specialty.
An explanation of benefits (EOB) clarifies differences between billed amounts and UCR payments, often labeling excessive charges as exceeding UCR limits.

Description

Test your knowledge on 'Usual, Customary, and Reasonable' (UCR) terminology used in medical reimbursement. This quiz will help clarify the UCR definition and its significance in healthcare billing practices. Challenge yourself to understand the nuances of medical service charges and reimbursement methodologies.