UCR Response Letter

July 24, 2015

If a charge is ever reduced by a payer because of “usual, customary, and reasonable” considerations, use this letter to send to a patient explaining UCR.

To download this letter, click here: UCR Response Letter

Dear (Name):
Thank you so much for your recent inquiry and for the opportunity to respond to your concerns relative to practice charges and insurance reimbursement.
This can be an area of confusion for all parties — patients, physicians and employers. Please recognize that (name of practice) carefully reviews its fee structure every year to ensure that charges are appropriate for the intensity of clinical service and required expertise, comparable to charges by other providers for similar services and sufficient to cover practice costs. We also strive to keep our charges affordable for patients.
The term “usual, customary and reasonable” is very misleading. In fact, insurance companies exercise great latitude in determining what they call usual, customary and reasonable charges. There are no regulatory guidelines to oversee such determinations. Different insurers use a variety of ways to determine what they will consider usual, customary and reasonable, including use of relative value scales (some from as far back as 1974) and comparison with amounts paid by other insurers or charged by other physician groups. The determination is also influenced by the insurer’s own goals for expenditure containment. It has been our experience that one or a combination of these factors often results in less than adequate reimbursement to our patients or our physicians.
This is a situation that frequently results in frustration and dissatisfaction for both those who pay substantial premiums for insurance coverage and those who provide high-quality, cost-effective care. We are as concerned as you about costs and out-of-pocket expenses for covered services. This is an ongoing issue for responsible physicians nationwide, not just in (your state).
It would be our recommendation that you request that your insurance company reconsider its reimbursement of the services we provide. To ensure that your “voice” is heard, we are forwarding a copy of both your inquiry and this letter to our state insurance commissioner, (name). Our complete office staff stands ready to assist you further with this matter. We hope this has been helpful to you.

(Your name)

To download this letter, click here:UCR Response Letter

Previous post:

Next post: