Non-Participating Providers and the Never-Ending Battle for Correct UCR Payment

Maximizing Usual, Customary and Reasonable Reimbursement

The “Usual, Customary and Reasonable" (UCR) for a procedure is an ongoing debate between non-participating physicians and insurance companies. When carrier fee schedules and reimbursement policies do not coincide with the realities of a practice’s UCR, physicians get short-changed.

You can maximize your reimbursement by implementing the following practical tips.

• Enlist a Service: Leverage available software and services. Companies like
Ingenix, among other useful offerings, provide solutions to help calculate UCRs. Remember that a true UCR is based on what providers with the same background and experience charge for the same service in your geographic region. Thus, the UCR for a particular procedure rendered by a spine surgeon in Bergen County may be different than in Gloucester County.

• Establish “Comparable” Reimbursements: Save your explanations of benefits
with highest reimbursement rates for particular CPT codes. Then use these
“comparables” as proof of your UCRs when an insurer disputes the level of
payment.

• Document Emergencies: Carefully track your emergency services. They are
typically reimbursed at 100% of the UCR.

• Obtain Pre-certification: For non-emergency services, obtain pre-certification
and verify payment terms with the carrier - by calling the phone number on the
back of the patient’s insurance card - before rendering services. Confirm that
you will get paid at the doctor’s UCR. Then document the approval in the
patient’s chart or your practice management software, including who you spoke to, when and the terms that were verified.

• Get Upfront Payment: Obtain pre-payment from patients whenever possible
and particularly when you have doubts about the availability of insurance or the patient’s ability to pay at a later date. A credit card is preferable for full recourse if there is a dispute.