Equity Adjustments in Customary Charge Screens

80.3.1.1 - Equity Adjustments in Customary Charge Screens (Rev. 1, 10-01-03) B3-5010.2 Once the MAC establishes the customary charge screens for a fee screen year, further increases (other than to correct errors) are permitted only in individually identified and highly unusual situations where equity clearly indicates that the increases are warranted. Requests for revisions in customary charge profiles are initiated only by physicians or other persons furnishing covered services. Such requests are neither encouraged nor discouraged, and each request is handled on the basis of its own merits. All of the following considerations are taken into account, as applicable, in determining whether unusual circumstances warrant a revision in a customary profile in a particular situation. • Time elapsed since last change was made in customary charge o Identify if the last change made in a customary charge for the service was in the past two or three years. Generally, the more time that has elapsed since the last change the stronger the case is for recognizing the current charge. o Take into consideration that a physician or other entity did not increase fees charged for a service because of the government’s request for restraint and this can be verified. This should be taken into account in determining whether unusual circumstances are present in a particular case. • Consider the amount of the requested increase and the relationship of the new and old charges to the customary charges of other physicians or other persons in the locality for the service. • Increases in Operating Expenses Used to Justify an Increase in Charges o The entity must specifically prove that increases in operating expenses are substantially above those resulting from general economic factors and the situation is unique.