UCR: Usual, Customary, & Reasonable

You will find that dentistry is quite sensitive about this term. This is because it leads the patient to believe that the insurance companies know what is "reasonable" or "usual" in our profession. Most people are led to believe that this UCR is an average of the fees charged by dentists in certain zip codes. This is not accurate and, in fact, if you ask five different employees of the same insurance company how they arrived at their UCR fees, you will likely get five different answers. The truth is that UCR fees are determined in many different ways by many different insurance companies. Ultimately, the UCR fees are the maximum fee that the insurance company will consider when determining the amount of reimbursement under your indemnity plan.

Example, you have 100% coverage for preventive care. If Dr. A charges $60 for a dental cleaning, Dr. B charges $75, Dr. C's fee is $85, Dr. D's is $90, and your plan has a UCR of $83 for a cleaning, then your reimbursement from the insurance company will be $60 for Dr. A's services, $75 for Dr. B's, and $83 for Dr. C and D's since both of their fees are above the insurance company's URC. Therefore, in reality, you had 100% coverage for Dr. A and Dr. B, 97% coverage for Dr. C, and 92% for Dr. D. This is not to say that Dr. C and Dr. D overcharged you. It is possible that your insurance company has not increased their UCR limits for several years, or taken into account that these two doctors practice in a neighborhood where the office rents are higher causing them to have to charge a bit more to cover expenses. Additionally, it is very possible that Dr. A has not increased his fees in several years and is not keeping up with the cost of providing care.

The frugal consumer might think, based on this description of UCR, that it is wise to "shop" for the lowest fees in the area for each procedure to lower his out of pocket expense for dental care. However, it is most likely that from office to office, the fees for each procedure will vary. A cleaning might cost $3 more in office #1 than office #2, but their cavity detecting x-rays might be $5 less. In the end, it all "evens out."

More important than shopping for the "cheapest" fee for each procedure is finding a dental home where you feel welcome and comfortable. Forming a trusting and longstanding relationship with your doctor and having someone who truly knows you and your teeth is invaluable.