Your staff should be coached on how to respond to patient inquiries about UCR amounts. Physician charge data. With this method, insurers use prevailing physician-charge data accumulated over time. Often an insurer uses the 75th percentile as the basis for UCR amounts. Relative value systems.
Insurers also employ relative value systems or scales published by private organizations.
Some of these value systems are history based, meaning that the values have been primarily determined through historical accumulation of physician charge data. Often a combination of approaches is used. By assigning higher allowables to less frequently used codes and lower ones to high-volume codes, the insurer can make its fees appear more attractive. Other factors are also involved in an insurer's selection of allowables for services, such as contract coverage provisions and budgetary considerations. For instance, the coverage provisions written as part of the policy may limit the amounts and the scope of benefits paid.