My provider wants to update his pricing to be charging the U&C for his area but
The guide I am thinking about may have been created by Inginex. Inginex is owned by United Healthcare. It has also been the subject in recent court cases and State investigations. One insurance company told us they pay at the 95% of Inginex's data. Our charge for a service was $125 but the insurance company said our fee, per Inginex was too high. My comment to this is. we are the only specialty in the geographical area where the care is provided. For example, you are in the desert. No other gas stations are around fo 200 miles. The price of gas is $3.00 per gallon. The Inginex data might say that the gas should be $1.50 per gallon based on usual and customary for the geographical area. This makes no sense. If you are the only gas station and you charge $4.00 then the usual and customary is $4.00. Its as simple as that. Here, Usual and Customary is a HUGE issue. State law mentions UCR but it states the Providers usual and customary charges. The HMOs have gone so far as to argue that the UCR is 125% of the Medicare allowable. One lawyer representing the HMOs stated that a providers charges is what the HMO reimburses a provider. To me, a providers charge is the fee he/she represents and bills for servics rendered, but I am not a lawyer, so what do I know. One insurance company recently decided to settle all claims paid at their UCR (125% of Medicare), at 239% of Medicare. Sounds nice, but, not reallyNow, the insurance company is demanding refunds for all claims paid at more than 239% of Medicare and they are now setting 239% as the usual and customary fee for non-par poviders in my state.