UCR; Usual Customary and Reasonable
Merlin Law Group
Published at : 25 Oct 2020
Attorney Nicole Vinson, located in our Tampa, Fl. office discusses UCR. Health Insurance claims are being denied by insurance companies every day. Usual, customary, and reasonable is a very frequent excuse used by insurance companies to not pay or underpay claims. Typically, you see this when a specialized treatment, maybe a surgery, with an out of network provider needs to be done and the patient calls ahead and gets pre-authorization for this surgery. Then the insurance company underpays the claim and the responsibility falls on the patient when they were expecting the insurance company to pay. The insurance company will pay what is usual, customary, and reasonable but unfortunately they are using this excuse to pay a small portion of a procedure because they claim it would have been reasonable for it to be much less. They say a like doctor with like experience at a like facility could have performed the same procedure for much less.
If you have experienced something like this as a patient or as a hospital, Merlin Law Group would be happy to review it if you provide the information in a timely manner so they can exercise the rights possible under the insurance agreement.