Ama Policy

Definition of “Usual, Customary and Reasonable” (UCR) H-385.923

Fee Schedules, OON-Payment Issues

1. Our AMA adopts as policy the following definitions:

(a) “usual; fee means that fee usually charged, for a given service, by an individual physician to his private patient (i.e., his own usual fee);

(b) a fee is ‘customary’ when it is within the range of usual fees currently charged by physicians of similar training and experience, for the same service within the same specific and limited geographical area; and

(c) a fee is ‘reasonable’ when it meets the above two criteria and is justifiable, considering the special circumstances of the particular case in question, without regard to payments that have been discounted under governmental or private plans.


2. Our AMA takes the position that there is no relationship between the Medicare fee schedule and Usual, Customary and Reasonable Fees.


Policy Timeline

Res. 109. A-07 Appended: Res. 107, A-13