Understanding Usual, Customary and Reasonable Fees in Health Care

Male Nurse

Male NurseInsurance policy holders have certain out-of-pocket fees that they must pay for, one of which is the usual, customary and reasonable fees or UCR.

What are UCR Fees?

Insurance companies monitor UCR fees, which they then use to determine if it makes sense compared to services charged by doctors in the area. If a doctor charges more than what an insurance company considers UCR, you may have to pay for the difference between the charged amount and the price covered by the policy you have.

CrystalClearRx.com cites that UCR fees have certain characteristics such as:

  • Fees charged by doctors for a service
  • It is within the price range that other doctors charge
  • It is for a necessary service under the current circumstances

The price of UCR fees charged for services depends on certain factors. Several medical insurance policies divide providers into “out of network” and “network” groups. Choosing an out of network doctor may require you to pay for some or even the entire service cost. An in-network provider may mean that you do not have to pay for possible UCR fees.

Drug Pricing

Other than worrying about potential UCR fees, policy holders must also be aware of drug pricing. The influence of physicians and prescribers play a major role in affecting the prices of drugs in the market as patients need their advice as to what medication to take.

The prevalence of pharmaceutical manufacturers makes it difficult to buy products directly from the source. The supply of pharmaceuticals involves several wholesalers that distribute medicine before they reach patients. This creates three or more transaction areas that hike prices up.

Several policy holders only consider the cost of medical services after they get it; the surprise comes when they realize their insurance does not cover all of their expenses. Knowing the UCR fees and factors that may affect drug prices reduces the possibility of an expensive hospital bill.