VA- Reasonable Charges Rules, Notices, & Federal Register

by  Christine Woolstenhulme, QCC, QMCS, CPC, CMRS
October 21st, 2019

Usual, customary and reasonable charges (UCR) are medical fees used when there are no contractual pricing agreements and used by certain healthcare plans and third-party payers to generate fair healthcare pricing. 

Where does Find-A-Code get their data for UCR?

Find-A-Code offers UCR fees gathered from the US Department of Veterans Administration (VA) using Geographically-adjusted charges and the 80th percentile conversion factors; this information can be found on the code information page (see example below) and is offered as a fee comparison with our UCR Pricing add-on.

Where are UCR fees located in Find-A-Code?

While on the code information page scroll down to the fees section and open the tab titled “UCR Fees”, the fees will be displayed for UCR, Workers Comp, as well as Medicare Billed and Allowed.

What information comes from the VA? 

The following information comes from the VA to give an understanding of accountability to the Federal Register, calculations and links to data sources used on our UCR pricing.  

Reasonable charges according to the VA is described as follows; Reasonable Charges are based on amounts that third parties pay for the same services furnished by private-sector health care providers in the same geographic area. In the past, VA used average cost-based, per diem rates for billing insurers. Reasonable charges are calculated for inpatient and outpatient facility charges, and for professional or clinician charges for inpatient and outpatient care.

Reasonable Charges Rules, Notices, & Federal Register

The VA determines the amount of the national average administrative cost annually for the prior fiscal year (October through September) and then applies the charge at the start of the next calendar year. Below are links to the Federal Register and data sources from the VA Website.

Inpatient:

Outpatient and Professional

Federal Register / Vol. 84, No. 189 / Monday, September 30, 2019 / Notices

References:

VA- Reasonable Charges Rules, Notices, & Federal Register. (2019, October 21). Find-A-Code Articles. Retrieved from https://www.findacode.com/articles/va-reasonable-charges-rules-notices-federal-register-35828.html

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