Joseph H. Lones III, DC, FCCC
I've noticed the phrase "exceeds usual & customary" as a footnote on several claim form evaluations, which when analyzed, is quite interesting.
Webster's dictionary contains the following definitions:
Usual -- adj: done, found, or used in the ordinary course of events: normal, regular (charged less than his usual fee), syn: usual, customary, habitual, accustomed can mean familiar or expected through frequent or regular repetition. Usual suggest something that occurs so frequently that it seems in no way strange or conspicuous---
Customary -- adj: 1: based on or established by custom--- 2: commonly practiced or observed: habitual, customary implies conformity with individual or social practices or conventions---
Exceed -- vb: 1: to be greater than or superior to: surpass (exceeds his earlier performance) 2: to go or be beyond limit or bound---
My fourth grade English teacher would have cringed if she saw this incomplete sentence (thought) -- one verb, two adjectives, and a conjunction. I can just see her scolding the inventor of this phrase and making this grown person sit another year in one of those tiny desks in elementary school.
Secondly, the definition of exceed in the phrase "exceeds usual and customary" -- Why are they attempting to cut the bill? When they acknowledge that I exceed (meaning to be greater or superior to) something, perhaps a superior adjustment?
Thirdly, the phrase usual and customary -- Any four-year-old can tell when an insurance form is handwritten or computer generated. They should also realize that it would be time consuming to charge different amounts to different patients, or for different visits for the same services. Thus, if the amount on the claim form is consistent, visit after visit, then they should recognize that the amount listed is my usual and customary, according to the definitions listed above.
Upon questioning an insurance claim reviewer concerning this definition, she stated that it pertains to the usual and customary fee in this area, not just my usual and customary fee. My reply was, "I wasn't aware that the patient was treated by these other doctors." So how, when, and where did they see the patient to make this determination for fees? She stated that they never saw this patient. It was based on their patients and fees. "Oh," I said, "Now I think I understand."
After all of this deliberation about the usual and customary charge, I found that it was getting late. The banks had closed, and I still had a few errands to run. I was hungry and had only $2 in my pocket.
Armed with this new knowledge about usual and customary charges, I decided that I could probably get a meal consisting of a hamburger and a Coke for about two dollars. I called the big three -- McDonald's, Burger King, and Wendy's -- and discovered that the price for such a meal would be about $1.49 including tax.
Completing my errands, I found myself sitting at a stoplight by the Hyatt Regency Hotel. My stomach started to growl to remind me of my hunger. I recalled eating a hamburger here once before and found the food to be quite good so I pulled into the parking lot.
The restaurant is quite nice. It is tastefully decorated with plants, with an indoor brook running through the center. There were a few other patrons talking softly and apparently enjoying their meals. The waiter was impeccably dressed in Hyatt attire. He very politely took my order of a hamburger, cooked well done, no pickle, extra mustard, and a Coke with lots of ice.
After a short wait he delivered my burger and Coke. It tasted great. Just as I remembered it from my last visit. Finishing the meal, I felt I had satisfied my hunger. I ask the waiter for the check. A few moments later he brought it, stated that I could either pay him or the cashier, and that he would be right back. He was then called upon by another patron.
I examined the bill and saw the charge was $4.76, exceeding the usual and customary. So I took a red pen out of my pocket and wrote the phrase "exceeds usual and customary" on the bill and added, "reduced to $1.49." I then took the $2 out of my pocket and placed it with the bill. Because he was such a good waiter I decided to leave him the 51 cents as a tip -- a full 25 percent.
It was getting late, I had finished with the day's work. I was tired and ready to go home to bed. As I was driving off, the waiter and the doorman came running towards me waving the $2. I rolled down my window and yelled, "That's okay. I don't want the change, you can keep it as your tip."
The more I think about the usual and customary idea, the more I think I like it. Using the usual and customary method I think I can now afford the new car (Lamborgninni) and new home in Manhattan.
