Robert A Foster, Jr
DMD/PC
Family and Cosmetic Dentistry
770-971-5119
1230 Johnson Ferry Place
Suite C-10
Marietta, GA 30068
What is UCR?
"Usual, Customary, and Reasonable"-UCR as insurances refer to it-may be one of the most misunderstood terms used in describing dental benefit plans. UCR plans may pay an established percentage of the dentist fee or what the plan considers a "customary" or "reasonable" fee limit, whichever is less.
Although these limits are called they may or may not reflect the actual fees that dentists in your area charge. Your explanation of benefits (EOB) may note that the fee your dentist has charged you is higher than the UCR reimbursement levels that the plan offers. This does not mean that you have been overcharged. For example, the benefits company may not have taken into account up-to-date data in determining a reimbursement level.
What we, in the dental field have questioned is -if the UCR is determined by areas-then why isn’t the reimbursement rate for our area the same for every insurance? It's NOT! There is NO regulation how insurance companies determine reimbursement levels, and companies are not required to disclose how they determine these levels. This results in wide fluctuations.
Each insurance company will determine payment according to a fee schedule that has been determined by their standards.
Your particular program may base its dollar allowance on a fee schedule which may not coincide with current acceptable fees. That schedule is directly related to the amount of premium that was paid for the insurance benefit.
Note: Dentists are not allowed to know what the UCR maximum allowable fees are for any procedure.