Private Third-Party Payer Fee Schedule Systems

Introduction When we consider fee schedule payment systems outside the Medicare and Medicaid realm, the number, type, and basis for payment become highly variable and quite specific to a given private third-party payer or commercial insurance company. This variability even extends to the different state Medicaid programs. One concept that does pervade this area is the concept of the usual, customary, and reasonable (UCR) amount for a given service or item. We started our discussion of the UCR concept in Chapter 3, and the discussion continues in greater depth in this chapter.