What is ucr in healthcare?

Where does Find-A-Code get UCR Data?Find-A-Code offers UCR fees gathered from the US Department of Veterans Administration (VA) using Geographically-adjusted charges and the 80th percentile conversion factors; this information can be found on the code information page (see example below) and is offered as a fee comparison with our UCR Pricing add-on. Reasonable charges are updated by the VA annually on January 01. We display the VA's data for our customers and have listed the VA's detailed information below from the VA; however, for additional questions on the VA's data and processes, please contact the Veterans Administration (listed below).

Understanding the 80th Percentile"80th percentile" charges are not the same as a fee multiplier.

When the VA did their survey of fee amounts, the fee amount they chose as the UCR amount is in the middle of at least 80% of the fee amounts reported. Like in a bell curve that covers X%, the middle or peak of the bell curve is the amount they chose.  The VA determines the amount of the national average administrative cost annually for the prior fiscal year (October through September) and then applies the charge at the start of the next calendar year. Below are links to the Federal Register and data sources from the VA Website.

VA Data SourcesThe VA uses multiple Reasonable Charges Data Sources and has them sorted by charge type on their website and where to obtain the data. Using the links below, the page will open up under "Payer Rates and Charges" from there, select the type of data, such as "Reasonable Charges Data Sources," and select the most current version of the Inpatient or Outpatient and Professional files. Rules and Notices such as the Federal Register are available and helpful in understanding where the Information used by the VA is coming from. Visit the "Payer Rates and Charges" page for information on Reasonable Charges Rules, Notices, & Federal Register.

Data Tables offer additional information on how the VA uses its UCR Data; please see the Reasonable Charges Data tables on the "Payer Rates and Charges" page.

Data Sources used by the VA when assigning UCR fees can be found on the "Payer Rates and Charges" page under Reasonable Charges Data Sources.

Charge adjustment factors are taken from the VA. See TABLE M. for Charge Adjustment Factors for Profesional services charge modifiers.

RVU Conversion Factors V4.235 Table L: Professional Services RVU Conversion Factor Geographic Area Adjustment Factors (GAAFs) by Zip Code  See data sources for information on where the VA gets RVU Data from see (Table 1. sample page).

After reviewing this information, if you have further questions, please contact the VA, Office of Community Care, Revenue Operations, Payer Relations and Services, Rates and Charges (10D1C1), Veterans Health Administration (VHA), Department of Veterans Affairs, 810 Vermont Avenue NW, Washington, DC 20420, (202) 382– 2521. (This is not a toll-free number) or 800-698-2411.

Information From the VA The following information comes from the VA to give an understanding of accountability to the Federal Register, calculations and links to data sources used on our UCR pricing.

Reasonable charges, according to the VA, are described as follows; "Reasonable Charges are based on amounts that third parties pay for the same services furnished by private-sector health care providers in the same geographic area. In the past, VA used average cost-based, per diem rates for billing insurers. Reasonable charges are calculated for inpatient and outpatient facility charges, and for professional or clinician charges for inpatient and outpatient care".

Inpatient

Outpatient and Professional

Anesthesia

Third-Party Pharmacy Prescription Administrative Charge

Once you are on the code information page on a specific code, scroll down to the fees section and open the tab titled “UCR Fees” the fees will be displayed for UCR, Workers Comp, as well as Medicare, billed, and allowed amounts.

The percentage calculations can be used for adjusting your fees to obtain a range of Low, Medium, or High pricing; it can also be used to adjust for modifier usage. UCR for CPT/HCPCS Code:

UCR for DRG Codes:

UCR Fees for Outpatient Facility:

Pro Fee CalculatorThe Pro Fee Calculator is an easy-to-use tool when calculating UCR fees for CPT and HCPCS codes.  Need to apply modifiers? Additional units?  The Pro Fee calculator can do this and more. For example, when using modifier 50, "bilateral procedure," the charge factor will be adjusted by 1.50; modifier 22, Unusual procedure, uses a charge factor of 1.25. Meaning your fee will change from 100% to 150 for the bilateral Modifier 50 and from 100% to 125% when reporting the 22 modifiers.  See Find-A-Code for a list of all CPT Modifiers and descriptions.

If you’ve ever been surprised by a medical bill, you’re not alone. Sometimes that surprise happens because your insurance company didn’t cover some or all of what your doctor charged for a medical procedure because it didn’t meet their “UCR,” or “usual, customary, and reasonable” rate.

Insurance companies use the UCR method to decide how much they will pay for an out-of-network medical service based on what a majority of other doctors in a geographic area charge. If your doctor bills above the insurance company’s UCR rate, they may not agree to cover it all, charging you a UCR fee to pay the rest.

If you use an in-network provider, and you have a managed care plan like an HMO, PPO, or POS, you don’t really have to worry about UCR fees. That’s because those providers have already negotiated with your insurance company and agreed to accept the UCR rate as their full payment. Sometimes, though, you may need to use an out-of-network provider, or you may have an indemnity plan (which is rare). That’s why it’s good to know how UCR fees work and how to avoid them if you can.

UCR stands for usual, customary, and reasonable, and it defines how insurance companies decide if what a medical provider charges for a procedure is equal to or less than the maximum amount they think should be charged.

Here is how insurance companies define the usual, customary, and reasonable criteria:

Usual: A charge is considered usual if it matches what an individual medical provider typically has charged patients in the past for the same or similar procedures or services.

Customary: A charge is customary if it’s within a range of fees that most other medical providers in a geographic area charge for the same or similar procedures or services.

Reasonable: A charge is considered reasonable if it meets both the usual and customary criteria or if it’s a special circumstance. That might include a rare or very difficult procedure.

How insurance companies come up with their UCR charges can be a bit of a mystery, but most set their UCR charges at the 80th percentile. That means that 80% of the medical providers in a given area charged equal to or less than the insurance company’s UCR rate.

Here’s how it works when it comes to how much they cover. Let’s say you tear your meniscus while jogging and you have surgery to repair it. You use an out-of-network surgeon who bills $6,000 for the procedure. But your insurance company’s UCR charge for that procedure is $5,000. If your insurance company typically pays 80% of your medical expenses before you meet your deductible, they would cover 80% of your bill up to $5,000. They would not cover the $1,000 above their UCR rate, which means you may need to pay the $1,000 UCR fee, in addition to your 20% coinsurance of the $5,000 UCR rate.

In many cases, insurance companies don’t count the money you pay above a UCR rate toward your deductible or out-of-pocket maximum. This means, if you regularly use out-of-network doctors, you could wind up paying a hefty amount in medical bills.

The good news is that most insurance plans, such as HMOs or PPOs, come with a large  network of providers, including doctors, hospitals, labs, and therapists. If you stay in that network, you won’t pay a UCR fee.

Medicare has its own version of UCR rates known as Medicare allowable charges. Any provider who agrees to participate in Medicare also agrees to accept the Medicare allowable charge rate as their full payment from the insurer. But some doctors who are non-participating providers can turn around and bill you for the difference. To help prevent that from happening, ask doctors if they accept Medicare assignment, which means they won’t ask you to pay the balance of a bill. You will, however, still have to pay your deductible and coinsurance.

Some Medigap, or Medicare supplemental plans, may also help pay for excess physicians charges.

There aren’t very many regulations that determine how insurance companies decide their usual, customary, and reasonable rates. Many use their own data to determine what local doctors are charging for procedures. Legally, though, insurance companies must tell you how they came up with a rate if you ask.

There are some basic rules, though, that insurance companies follow to decide if a charge is usual, customary, and reasonable. The charge is consistent with what the medical provider has charged in the past (usual), it fits the range that other area doctors are charging (customary), and it either meets both the usual and customary criteria or it’s a special circumstance (reasonable). If the insurance company thinks your medical provider’s charge doesn’t meet that criteria, they will only agree to pay the UCR rate, and you could have to pay the rest, which is the UCR fee.

The best way to avoid paying UCR fees is to use in-network providers. Sometimes, though, that’s unavoidable. If you know in advance that you’ll be using an out-of-network provider, ask the doctor how much they will bill for the procedure or service. Then ask your insurance company what their UCR charge is for that procedure. You may be able to get your doctor to agree to accept the insurance’s UCR charge as payment in full.

You also may be able to get your insurance company to pay more than the UCR rate if the doctor writes a letter explaining why they had to charge more for a certain procedure. It’s also possible your insurance company may agree to adjust your bill post-procedure if you can show that multiple other doctors in the area charge a similar amount to what your doctor billed.

Fortunately, when it comes to prescription drugs, it’s not common to have to worry about UCR fees. That’s because the UCR charge for prescription drugs is the amount someone without insurance would pay for a drug. This is also referred to as the “cash price.”

The amount paid for a medical service in a geographic area based on what providers in the area usually charge for the same or similar medical service. The UCR amount sometimes is used to determine the allowed amount.