Author Topic: Usual, Customary, and Reasonable price issues  (Read 1337 times)


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Usual, Customary, and Reasonable price issues
« on: November 16, 2015, 12:13:14 AM »
Hi all, I'm new to this site so please excuse (or provide feedback on) any issues with my etiquette.

I'm being charged excessively by SFGH (San Francisco General Hospital) for several items related to an emergency room visit, but the most egregious is the triage (the actual them-taking-care-of-you part) itself. Is there any way to talk them or the city down in price? I've tried, but it wasn't very heavy handed since I don't really know what I'm doing.

I've done price comparisons. According to, the UCR (usual, customary, and reasonable) price for level 4 ER treatment in San Francisco is $640. UCSF, a world renowned hospital, charges a little more (understandable given their quality) which is a little under $900. SFGeneral? A whopping $4438. This is almost %700 the UCR rate and, I hate to say it, but SFGeneral is not known to be a top hospital in the area so I don't know how this can possibly be justified. I would genuinely like to know what their argument is besides "I'm sorry, I don't set the prices". I'm on the hook for covering thousands more than my out-of-pocket maximum due to my insurance only paying the UCR rate.

There was a lawsuit but I don't think I'm covered:

I've done my homework, but I'm happy to do more. Please let me know what I can do to help myself.

« Last Edit: November 16, 2015, 12:14:48 AM by sgomez11 »


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Re: Usual, Customary, and Reasonable price issues
« Reply #1 on: November 16, 2015, 10:59:35 AM »
I answered some of this on the other post, but have they given you a detailed break down of all of the fees?  Do they par with your insurance? 
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Re: Usual, Customary, and Reasonable price issues
« Reply #2 on: November 16, 2015, 06:46:57 PM »
Are these facility charges or professional charges.  If they are facility your insurance company usually will do what's called a DRG audit. They will negotiate the lowest rate for you..

If these are professional fees, Michele is right, we need a better breakdown of CPT codes, amount billed and amounts over U&C.   Since they are telling you they are over U&C I'm guessing the provider is not a participating provider with your insurance.. that's ok though. There is a LOT of wiggle room with disputing fees over U&C, you didn't even have to do all that homework.   If you can better provide a breakdown for us we might be able to help. You will need the help of the physician/surgeon.
Linda Walker
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