Usual, Customary and Reasonable (UCR) Denials

When providers render “out of network” care, reimbursement is limited to the UCR charge.  The payer is bound to determine UCR in accordance with the applicable provisions in the policy or plan.  Payers use one of a plethora of terms for UCR, including usual and reasonable, reasonable, maximum allowable, allowable, etc.  Regardless of the label, these denials all fall under the same category.  Payers are severely lowering the amount of reimbursement considered to be UCR in effort to reduce benefit payments, strong arm providers into entering contracts that allow steep discounts, and line the pockets of insurance company executives.  Despite the increases in healthcare costs and medical inflation, payers have reduced the amounts it considers to be UCR.

Providers often accept incredibly low reimbursement due to these reduced UCR determinations because of the difficulty of appealing these determinations.  Providers are also tempted by the ability to balance bill the patient for the unpaid balance.  While there are typically no legal impediments to balance billing patients, there are often financial limitations on the patients’ ability to pay.

TGF has the expertise and resources to appeal erroneous UCR determinations and obtain reimbursement required under applicable plan or policy language.  Payers must pay benefits in accordance with the terms of the applicable plan or policy, but payers draft provisions to create hurdles and red tape to prevent successful appeals.  TGF can navigate these obstacles and cut through red tape by identifying applicable laws and advocating for provider and patient rights.

Recently, payers have increasing turned to “expert” repricers and “cost containment” companies to determine lower UCR rates with complex supporting data.  Incredibly, these “experts” often receive more money for determining UCR than providers receive for rendering the underlying treatment.  TGF effectively combats these repricers and advocates for appropriate UCR determinations.

  • In an effort to limit benefits, strong arm providers into entering contracts for reduced reimbursement, and line the pockets of insurance company executives, insurers have reduced UCR rates despite increases in costs
  • Providers often accept low UCR determinations rather than disputing the insurer’s partial denial because they can usually balance bill the patient and the insurer’s appeals processes are time consuming and difficult to navigate
  • Insurers and GHPs are frequently engaging “expert” repricers and “cost containment” solution companies to determine UCR rates and discourage providers from challenging their conclusions
  • These repricers are often paid more for determining UCR than providers are paid for rendering services
  • TGF can appeal erroneous UCR determinations and obtain reimbursement at reasonable rates
  • Insurers and GHPs must follow the terms of their plan documents—and those terms rarely allow for exceptionally low UCR determinations.  If the UCR rate seems too low, it probably is
  • TGF expertly enforces providers rights in this area whether the plan is governed by ERISA, state, or other law