Are Usual and Customary Charges Reasonable?

The Resource-Based Relative-Value Scale Reforms for Physician Payment

Although the “usual, customary and reasonable” concept may have been reasonable and workable as a basis for [physicians] billing individual patients, it has been a failure as a basis for reimbursement from insurance funds. Because it contains none of the limits or standards that are applied to other services covered by insurance, the charges for medical services have escalated, with little or n...

Physician customary charges and Medicare payment experience: Study findings

Customary charges have had significant impacts in determining reasonable prices under the historic Medicare physician payment system. This article contains new, comprehensive information on customary charges as well as data aggregated at the physician level. These baseline data have some important policy implications, such as the study findings, that indicate that the Medicare fee schedule is l...

Coerced Contracting is Not a Reasonable Solution to Balance Billing

Regarding the article on access to in-network emergency physicians, the authors conclude that a solution to the lack of access to in-network emergency physicians at many hospitals may be to require plans to contract with these physicians at hospitals that are in-network with the plan (if I understand their approach correctly). Though this mandate might be helpful in some cases, it is just as li...

Looking for the usual customary reasonable relationship.

Physician losses from Medicare and Medicaid discounts: How real are they?

Physicians' claims that extensive Medicare and Medicaid fee discounting imposes an inequitable burden on them are examined using survey data from the Health Care Financing Administration on 5,000 primary care physicians. A definite fee hierarchy is documented, with the physician's usual charge at the top and Medicare and Medicaid allowables at the bottom. Under usual, customary, and reasonable ...