Your ABA Agency Has Billing Rates. But Do You Have a UCR?

Most ABA agencies bill every week or every day. Submitting claims to Medicaid. Billing commercial payers. Processing payments. The billing function is running.

But there’s a difference between having billing rates and having a usual and customary rate (UCR), and most ABA agencies only have the first one.

That distinction matters more than most leaders realize.

What Is a Usual and Customary Rate?

A usual and customary rate (which is also called a chargemaster rate or a standard fee schedule) is the amount a provider bills to all payers for a given service, before any contractual adjustment is applied.

Every payer gets the same bill: Medicaid, Blue Cross, UnitedHealthcare, self-pay. The billed amount is identical across the board. Each payer then applies its own contracted rate or fee schedule, which determines what it actually pays. The difference between the billed charge and the allowed amount is the contractual write-off.

This model (billing a single standard charge to all payers) is the industry standard for healthcare providers. And for ABA agencies billing under CPT codes 97151 through 97158, it’s not optional.

What Most ABA Agencies Actually Have

When we ask some ABA agency leaders what their billing rates are, the answers we often hear usually sound something like this:

• “We bill whatever our payers pay us.”
• “Our billing company set our rates when we opened.”
• “We have rates in the system, but I couldn’t tell you how they were determined.”
• “We just charge $X per unit across the board.”

None of these is a usual and customary rate. And none of them are compliant.

What these agencies have are contracted rates — amounts negotiated with or accepted from individual payers. They may have default entries in a practice management system that someone entered years ago. What they don’t have is a documented, benchmarked, defensible standard charge that was deliberately set and can be justified if someone asks.

Why It Matters

This isn’t a theoretical concern. Operating without a properly documented UCR creates several distinct risks for ABA agencies.

State Medicaid compliance exposure

Most state Medicaid programs, whether fee-for-service or managed care, have requirements around consistent and appropriate billing. Many states require providers to bill their standard charge, and some explicitly require that the billed amount not fall below what the provider charges other payers for the same service. 

The specifics vary by state. But if your state Medicaid program or MCO ever audits your billing practices and asks to see your standard fee schedule and the methods behind it, you’ll need to be able to produce one. “We bill what the MCO pays us” isn’t a compliant answer in most states, and it’s not a defensible one anywhere.

Commercial payer contractual risk — and the MFN problem

Many commercial payer contracts contain something called Most Favored Nation (MFN) clauses. In plain English, an MFN clause requires you to charge any that payer at least as much as you charge the lowest-paying payer you work with. It’s the insurance company’s way of making sure you’re not giving a better deal to anyone else.

Here’s where things get serious for ABA agencies that haven’t set a consistent UCR.

Imagine you’re billing your state Medicaid program at a rate that reflects what Medicaid actually reimburses — say, $12 per unit for CPT 97153. You haven’t thought much about it because that’s just what Medicaid pays. Meanwhile, your commercial payer contract says Blue Cross will pay you $15 per unit for the same code.

If Blue Cross has an MFN clause in your contract and discovers that you’ve been billing Medicaid at $12 while billing them at $15, they may argue that under the MFN clause, your “lowest rate” is $12, and therefore that’s all they owe you too. Retroactively. For every claim you’ve submitted.

That’s not a hypothetical. That’s a real contractual mechanism, and it can result in:

• Demand letters requiring you to refund the difference between what you were paid and the “corrected” lower rate
• Withholds against future payments while the payer conducts a review
• Contract termination
• Exclusion from the payer’s network

A documented, consistently applied UCR — set above all payer reimbursements and applied uniformly — is what protects you from this scenario. It demonstrates that your standard charge is the same regardless of who’s paying, and that Medicaid’s lower reimbursement reflects their contracted allowance, not a discounted billed rate.

Chronic underbilling

If your billed rate is at or below what a payer would have allowed, you can never recover that difference. The claim closes, and the lost revenue is permanent. There’s no system alert when a rate is set too low. Over hundreds or thousands of claims, the financial impact can be significant.

Rate compression over time

UCR benchmarks move and change with time. FAIR Health updates its percentile data annually. TRICARE maximum allowed amounts adjust each May. Medicaid fee schedules change. An agency that set its rates in 2019 and never revisited them is almost certainly billing below current market benchmarks, and falling further behind every year.

Audit vulnerability

When an auditor (Medicaid, commercial, or otherwise) requests your standard fee schedule and the documentation behind it, ansswering by saying “That’s just what we’ve always billed.” doesn’t protect your agency. A documented chargemaster with a clear benchmarking method does.

What a Defensible UCR Actually Requires

Setting a compliant, defensible UCR isn’t a matter of picking a number and entering it into your billing system. It requires a documented benchmarking process that considers multiple reference points.

At minimum, a defensible UCR for an ABA agency should be benchmarked against:

• Your state Medicaid fee schedule (this is the regulatory floor and your chargemaster must exceed it)
• Medicaid rates from other states, for regional context
• Commercial payer market ranges for your geography
• FAIR Health usual and customary percentile data for your market area

The resulting chargemaster rate should exceed all known payer reimbursements in your market and fall within the 75th to 80th percentile of FAIR Health charge data. That combination is what makes a rate both financially sound and defensible under scrutiny.

And it needs to be reviewed annually. A UCR analysis isn’t a one-time document. It requires regular updates as Medicaid rates change, commercial market rates shift, and FAIR Health data refreshes.

The Documentation Piece That Most Agencies Miss

Even agencies that have thought carefully about their rates often skip the documentation step, and that’s where compliance actually lives.

A compliant chargemaster rate isn’t just a number in a spreadsheet. It’s a documented report that includes:

• The rates themselves, broken out by CPT code and provider tier
• The benchmarking methods used to derive them
• The data sources consulted, with dates
• The effective date of the fee schedule
• A review and update date

This document is what you produce in an audit. It demonstrates that your billing rates were deliberately set, methodologically sound, and consistently applied. Without it, even a reasonable rate becomes difficult to defend.

This Isn’t Just a Billing Department Issue

ABA agency leaders may treat billing as a function handled by someone else. The billing company sets the rates. The front office manages the claims. Someone else handles the payer relationships.

But when an audit lands, it lands on the organization. The question of whether your rates were set appropriately, documented properly, and applied consistently is a compliance question, not just a billing question. And it belongs in the compliance program.

If you don’t know what your standard fee schedule says, how your rates were set, or whether your agency could produce a defensible chargemaster document on short notice, that’s worth knowing now — not when someone asks for it.

Want to go deeper on this topic?

On June 25, 2026 on BehaviorLive, Michael Fabrizio will present The Rate Nobody Set: What ABA Leaders Don’t Know About Their Own Billing — a 50-minute live session covering what UCRs are, what’s at stake when you don’t have one, and what a properly benchmarked chargemaster actually looks like. Register here.

If you’d like to start evaluating your agency’s current practices before the event, the free UCR Readiness Self-Assessment is a 14-item checklist that’ll show you exactly where your agency stands. Download it here.

And if you’re looking for ongoing compliance support — including AI-assisted tools to help you build your own UCR chargemaster report — the ABA Compliance Collective is where that work happens. Learn more at abacompliance.com/collective.