The customary charge is the amount that best represents the actual charges made for a given medical service or by other persons who supply other medical and health services to the general public. Therefore, obtain information on the customary charges from the following sources:
• Physicians and other persons not only from the Medicare program;
• Any other available sources;
• Other contractor programs;
• Other insurance programs;
• Federal Employee Health Benefit Program;
• TriCare;
• Any studies conducted by State or local medical societies;
• From public agencies;
• Any data volunteered from other sources.
Where circumstances warrant, MACs may also ask physicians or other persons for their charges for services rendered to the public in general. MACs should validate any information on charges obtained from sources against claims.
A. Charges for Rare or Unusual Procedures
In suchA/B MACs (B) may incur situations where a new or rare procedure is performed and information on customary and prevailing charges is difficult to obtain.situations, in order to make the reasonable charge determination:
a. Obtain data, if possible, on the charges made for the unusual or rare procedure in other areas similar to the locality in which the service was rendered; or
b. Consult with the local medical society regarding the appropriate charge to be made for this procedure.
A relative value scale may be used together with available information about the physician’s customary charges and about the prevailing charges for more frequently performed services in the locality in order to fill gaps in the data available. Where there is insufficient information, consult with any medical authority that would be helpful, such as the medical personnel within the A/B MAC (B), the local or State medical society, or hospital medical personnel. In assessing the value of the procedure, the medical personnel should take into consideration:
a. Its complexity;
b. The time needed to perform the procedure; and
c. The prevailing charges in the locality for other procedures of comparable complexity.
A/B MACs (B) then determine reasonable charge for a given service on the best available medical opinion and information on customary and prevailing charges.
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