Wiki Usual and Customary ?

[terry4162]

Good Afternoon - I have a physician asking the following and I'm hoping someone can help me with the correct answer;



We have a patient's whose insurance states that they will pay what 60% of usual customary.



What is usual and customary for in office balloons, Is that 60% of the billed amount or 60% of the paid?



31295/ 31296/ 31297



Thanks

 

[CodingKing]

U&C is typically an average charge in a geographical area. There's a few vendors that have vast databases of claims and put the averages rate usually by the first 2 or 3 digits of the zip code. Even if 2 carriers use the same company to get the U&C numbers each may price it at a different percentiles. Its probably best to query the carrier the Patient has insurance with to see if they will disclose the amount