Dealing with Issues with the UCR
Part 2, Chapter 4: Traditional Individual and Group Plans, Doctors' Bills Page 7
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However, if the UCR is only $85, the insurer will view that amount as the maximum it will consider in terms of reimbursement, rather than the $100 amount of the bill itself. In that case, the maximum reimbursement the insurer will provide will be $68 (80% of $85), and you will be responsible for paying the remaining $32. That $32 includes the $17 co-payment and the $15 that the insurer considered to be above the UCR.
The percentile that your insurer uses to determine the UCR may also have a significant effect on reimbursement. (See "Problems Related to Percentiles," below.)
In some cases, once an insurer has determined the UCR, there may not be a great deal you can do to change that determination. Many insurers appear to consider their UCR analyses -- and the database on which those analyses are based -- to be private information, and they seem to be reluctant to share that information with consumers. That obviously makes it difficult for a consumer to review the way in which the data base has been established or the process that was used to determine the UCR.
Because of that difficulty, it's usually better to try to prevent such situations from occurring whenever possible by using the predetermination of benefits process in advance of treatment in all non-emergency situations that involve significant costs (See Chapter 3). If it's not possible to use the predetermination of benefits process prior to treatment, and the eventual reimbursement provided by your insurer turns out to be far lower than the provider's bill, there are several steps you can take that may be helpful in some cases.
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