Health insurer accused of overcharging millions – United Health Care/Oxford Insurance 50 Million Fine

The Attorney General states that Ingenix, owned by United has been manipulating numbers, and if you check in to some of the prior posts here you can also see how firms of such are using your drug rap sheets too. It comes back to the algorithms or formulas used by the insurance companies to create the decision making process, you know like the ones used on Wall Street until the bottom fell out.

The computers kick out what the algorithms call for based on the programming set up. Having written many SQL statements in my lifetime, the code does what the programmer writes and displays it on the screen for us as end users to work with for our decisions.

But there’s perhaps one little element of the puzzle missing here, Audit tables, just like small businesses use with their auditors with Quick Books to connect and run some code and check on the accuracy of the reporting and data entry, so when might we perhaps expect maybe some of the same with the agencies that govern risk management businesses? Ingenix uses algorithms like everyone else out there to create their decision making processes. BD

This brings me back around once more to a classic post:

The 2 New Hot Words in Healthcare: Algorithms and Whistleblowers

From a prior post: Prescription risk scores

“Did you know there's a market for your prescription data? Insurance companies are buying prescription data collected from companies like Milliman Intelliscript and Ingenix to help them make insurance coverage determinations.
Right now lawmakers are trying to figure out how to oversee a health-industry shift to computerized records and insurers have started testing systems that tap into prescription drug information.

Milliman Intelliscript, part of the Milliman Company, collects data from Pharmacy Benefit Managers (PBMs) that are not covered by the Health Insurance Portability and Accountability Act of 1996. Then insurance companies pay a small fee to obtain the data, which they use to deny or approve claim requests.”

“Ingenix, a Minnesota-based health information services company that had $1.3 billion in sales last year -- and Wisconsin-based rival Milliman -- say the drug profiles are an accurate, less expensive alternative to seeking physician records, which can take months and hundreds of dollars to obtain.

One of the nation’s largest health insurers has agreed to pay $50 million in a settlement announced today after being accused of overcharging millions of Americans for health care.

The New York attorney general’s office launched an investigation after receiving hundreds of complaints about Oxford Insurance and its parent company, UnitedHealth Group, which claims to rely on “independent research from across the health care industry” to determine reimbursement rates. In actuality though, it relies on Ingenix, a research firm owned by UnitedHealth Group.

New York Attorney General Andrew Cuomo says Ingenix has been manipulating the numbers (algorithms, BD) so insurance companies pay less. In a just-released report, he contends that Americans have been “under-reimbursed to the tune of at least hundreds of millions of dollars.” Although UnitedHealth Group and Oxford Insurance were the only entities investigated, other major insurers use Ingenix, including Aetna, CIGNA and WellPoint/Empire BlueCross BlueShield.