Determinations of Reasonableness

What is Reasonable?

In the legal world, “reasonableness” is determined by answering the question, “what amount would a willing seller sell to a willing buyer under the same or similar circumstances?” In the medical world, this term is called UCR – usual, customary and reasonable. The American Medical Association (AMA) has defined UCR as:

  • A “usual” fee means that fee that is usually charged for a given service by a specific provider to its private patients;
  • A “customary” fee is that fee which is within the range of usual fees currently charged by similar providers; and
  • A “reasonable” fee is that fee which meets the above two criteria and is justifiable, considering the special circumstances of the particular case in question, without regard to payments that have been discounted under governmental or private plans.

The AMA has also stated that there is no relationship between the Medicare fee schedule and Usual, Customary and Reasonable Fees.

In today’s complex world of medical pricing, it is important that the determination of reasonableness is performed with the above guidance in mind. Abacus Analytics will evaluate medical charges and issue a report detailing, per charge, whether the charges fall within the range of UCR charges. The report will be signed by a highly-credentialed expert who is capable of testifying in court or deposition if necessary.

How to Get Started?

If you are interested in receiving a medical charge analysis and opinion on reasonableness, please contact us at info@medicalcostexperts.com or 844-MED COST. In as little as 48 hours and for as little as $295 dollars, Abacus can get you the information you need.

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