If you’ve received a reduced payment from a PIP insurer that doesn’t match your bill, you’ve likely encountered a Usual and Customary Deduction. These deductions are made when insurance companies claim that the amount billed by a medical provider exceeds the “usual and customary” rate for similar services in the region.
While insurers may present these cuts as routine, Massachusetts PIP law does not specifically authorize arbitrary reductions based on vague internal benchmarks. That’s why Usual and Customary Deduction challenges have become one of the most common and important legal disputes for medical providers today.
At The Massachusetts Personal Injury Protection Lawyers, we fight these underpayments aggressively to ensure hospitals, imaging centers, and therapy clinics across the state get reimbursed fairly and in full.
Insurers use Usual and Customary Deductions to save money—plain and simple. They rely on outdated databases, internal fee schedules, or third-party pricing software to determine what they believe a procedure “should” cost. When your actual billed amount exceeds this figure, they reduce your payment accordingly—without consulting you or verifying the accuracy of their source.
These reductions:
Are not reviewed by licensed physicians
Often disregard medical necessity or treatment quality
May violate your rights under Massachusetts PIP law
The result? Providers like you are left underpaid for services already rendered. That’s why challenging Usual and Customary Deductions is not just an option—it’s a financial necessity.
When you receive a PIP payment that’s lower than the billed amount, the explanation of benefits (EOB) often states the adjustment was due to a “usual and customary rate.”
Under Massachusetts General Laws Chapter 90, Section 34M, PIP insurers are required to pay for all reasonable and necessary medical expenses. The law does not allow insurers to replace the provider’s professional judgment with automated pricing software or internal policy.
In fact, courts in Massachusetts have found that unsubstantiated “usual and customary” adjustments can violate the provider’s right to fair reimbursement under the PIP statute.
That’s why legal action is often required to reverse these improper deductions. And when done correctly, it works.
These deductions impact almost every type of medical provider that bills auto insurance in Massachusetts. If you’ve ever received partial payments with no clear justification, you’ve likely been affected by this tactic.
MRI and imaging centers
Physical therapy and rehabilitation clinics
Orthopedic practices
Chiropractic providers
Pain management centers
Community health centers
Hospitals and urgent care facilities
Whether you’re billing for diagnostics, treatment, or ongoing care, Usual and Customary Deductions can significantly reduce your expected revenue if left unchallenged.
The first sign that a payment has been reduced due to Usual and Customary Deduction is often buried in the insurer’s explanation of benefits. These statements may include vague reasons, unclear codes, or reference third-party systems like FAIR Health or Ingenix.
“Charge exceeds usual and customary rate”
“Adjusted to allowed amount”
“Based on internal fee schedule”
“Repriced by third-party vendor”
“Payment limited to fair market value”
If you see any of these, don’t write it off—challenge it.
At The Massachusetts Personal Injury Protection Lawyers, we use a step-by-step approach to challenge underpayments caused by unjustified deductions. Our attorneys are skilled in identifying legal weaknesses in the insurer’s rationale and applying pressure through proper legal channels.
Detailed Claim Review
We analyze your bills, the payment received, and the insurer’s EOB.
Legal Demand Issued
We draft and submit a letter demanding full payment under MA law.
Documentation Support
If needed, we gather CPT codes, provider qualifications, and market rate comparisons.
Litigation Filed (if unresolved)
If the insurer fails to respond, we escalate to court proceedings.
Full or Corrected Payment Collected
Once resolved, you receive the reimbursement you were originally entitled to.
All of this is handled on a contingency basis—you don’t pay unless we win.
Our firm has successfully handled hundreds of cases involving Usual and Customary Deductions. We know the billing codes, the insurer tactics, and the legal strategies that work.
Billing companies and internal staff can send follow-up letters or appeals—but they often stop at administrative pushback. Insurers rarely reverse Usual and Customary Deductions without legal pressure. Our firm brings the legal leverage necessary to demand compliance.
Working with us means:
You get legal support, not just billing appeals
Every claim is backed by case law and statutory authority
Insurers respond faster to attorneys than billing reps
You stay informed while we handle the heavy lifting
When you want results—not just excuses—we’re the partner your practice needs.
Even a small deduction per claim can result in major losses over time. For example, a $45 cut per patient, spread over 20 patients a week, can mean $3,600 per month in underpayment—or nearly $45,000 per year.
And that’s just one provider.
Now imagine that multiplied across departments, clinics, or regional practices. That’s why Usual and Customary Deduction Challenges are more than just cleanup work—they’re a high-impact recovery strategy.
If your facility is seeing consistent underpayments with vague reasons, it’s time to take a closer look. Insurers may be using Usual and Customary Deductions to cut costs—at your expense.
Let The Massachusetts Personal Injury Protection Lawyers step in and recover what you’ve earned. The consultation is free, the process is simple, and the results speak for themselves.
Contact our legal team today for a free case evaluation and start recovering your unpaid PIP claims. No upfront fees — just results.
We handle the legal heavy lifting so your team doesn’t have to. From identifying violations of PIP law to aggressively pursuing litigation when needed, we tailor our strategy to fit your goals. And because we operate on a no recovery, no fee basis, there’s no financial risk to your practice.
At The Massachusetts Personal Injury Protection Lawyers, LLC, we focus solely on helping medical providers recover what they’re owed — quickly and effectively. Our firm covers all filing costs upfront and never charges a fee unless we win your case. With personalized legal strategies and statewide service, we make PIP collections simple and stress-free.
We exclusively serve hospitals, clinics, and healthcare professionals across Massachusetts, giving us unmatched insight into PIP law and provider rights.
From claim review to litigation and appeals, we handle everything — so your staff doesn’t have to deal with paperwork, insurers, or court filings.
Our services are contingency-based — you pay nothing unless we recover funds for you. No upfront costs, no hidden fees, just results.
