HomeMSH InternationalNews releasesMenuUnderstanding Usual, Customary and Reasonable Charges vs. Actual Charges

Even if you are “fully-insured” by your health insurance plan, out-of-pocket expenses may still apply such as deductibles, co-payments, or co-insurance. Make sure you read your policy carefully as soon as you are enrolled in order to understand your coverage and to avoid any surprises when you receive your reimbursements.

What are UCR charges?

In order to control the healthcare costs, some policies will cover you according to usual, customary and reasonable (UCR) rates. These rates are the average cost of the treatment you are seeking in your location, calculated with several factors such as the geographical area of the service provided and the type of service. Your reimbursement will thus be based on the UCR charge and not on the Actual charge that appears on your bill, so you may be responsible for the difference between these two amounts.

In addition, the cost of your treatment may vary depending on whether your practitioner is part of our medical network or not. Our worldwide medical network includes +860,000 healthcare providers (hospitals, clinics, general practitioners, specialist, etc.). Visiting an in-network provider will ensure a good quality of health care at a cost that is usually under the UCR rates.

What should I do before receiving care? 

>> Find out about in and out-of-network practitioners: call us or use the search tool on your members’ area.
>> Read your insurance policy to see if you are covered for the actual charges of a treatment or for UCR charges. Our in-house doctors can give you the UCR rate for the treatment you are seeking in your location, so you can expect the amount of your reimbursement before receiving care.

Example - Doctor Visit 
Here is how to calculate the amount you would be responsible for:

> Actual Charge $200
> UCR Rate $150
> Co-insurance set by your policy to 20% of UCR rate $30
> Difference between Actual Charge and UCR rate $50
    >> TOTAL $80


Actual charges The amounts charged by your healthcare provider
UCR charges The amounts that the carrier will reimburse depending on your policy (100%, 80% ...)
Co-payment The amount that you are required to pay for your treatment
Co-insurance The percentage of the billed amount that is not reimbursed by the carrier (0%, 20% ...)
Deductible The amount (per person, per year) for which you are responsible before the carrier starts reimbursing your expenses. You can elect a deductible as an option in order to lower your premium.


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