Usual, customary and reasonable charges, or UCR, are the amounts determined by insurance companies that are most frequently charged for services and supplies in a given region. Health plans use the UCR to determine how much to pay doctors and hospitals with whom they don’t have a negotiated rate. Typically plans will pay 70, 80 or 90 percent of the UCR to out-of-network providers, leaving patients responsible for the balance of what their doctors or hospitals actually charge for services.
But it’s an area where common English and insurance jargon diverge. That’s because insurance companies have different ways of determining these charges. If they take a more aggressive approach, they can set the UCR at lower rates, shifting more of the cost to patients. And doctors must deal with angry calls from patients asking them why they charge more than the going rate or why they don’t charge a “reasonable” fee.
To make things more difficult, insurance plans don’t reveal what the UCR rates are, so often a patient won’t know how much he’s on the hook for until he receives the bill.
If you know you’re going to be seeking care outside of the network, it’s a good idea to ask your insurer to talk to that provider to see if he or she will accept the UCR as payment in full — or to arrange a discounted fee.
— Markian Hawryluk, The Bulletin