HEALTH BENEFITS
ARTA BENEFIT PLANS
Usual and Customary Fees
Gary Sawatzky | Chief Operating Officer, ARTA
Every year, the ARTA Health Benefits Committee reviews submissions by members as part of the benefit plan design review.
The Committee reviews every submission from members to determine if the suggested plan change would fit within ARTA’ s Benefit Plans. If it does, a financial report is completed to determine how much it would cost members to implement, and the cost is then weighed against the potential benefit and the level of demand.
One aspect of the plan that is automatically reviewed, regardless of member input, are the Usual and Customary Fees that determine the basis of payment for certain eligible claims. The Committee considers real claims data from the past year
relevant to each specific good or service. If the actual submitted amounts are significantly different from the current Usual and Customary Fees in place, often due to inflation, a change is typically made. The submitted amounts are determining factors for what ARTA will pay for each claim, such as paramedical practitioner claims.
For example, in 2024 there were 66,600 claims submitted for physiotherapy treatment, with an average treatment costing $ 92.45. The Usual and Customary amount that was in place for the 2024 – 25 plan year was $ 90.00, meaning the average submitted amount in 2024 exceeded the base amount ARTA had established under the benefit plans, which meant an increase to the Usual and Customary Fee appeared to be in order.
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