This is perhaps the classic statement here:  "You ask me how are their 'usual and customary' rates being determined?" Rockefeller said. "I don't know."  It comes back to algorithms, formulas that determine the usual an customary fees.  Anyone who had read any number of postings here now knows what that means as I refer to it frequently.  All businesses use them as business intelligence software is what is used to make decisions and calculations, and everyone uses and create algorithms to help them reach the desired results,…like Wall Street did too.  They also use drug profiles.

From a prior post in August 2008

"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. They note that consumers authorize the data release and that the services can save insurance companies millions of dollars and benefit consumers anxious for a decision.”

One thing for sure, the Government and Consumers alike are learning the power of business intelligence and what happens when there is lack of it on one side, like a PC running with no anti-virus protection and the Trojans march in. 

Ingenix's price database is so widely used to set reimbursement rates that the litigation is believed to affect seven out of 10 people with health insurance. (Note: this is business intelligence software at work)

Will Greed lead to Meltdown of the Health System?
Sorry, folks, but it’s true: You are for sale

Ingenix had a website set up also to help consumers find a match with doctors they announced back in June.  It includes aggregate claims data from 27 million episodes of care, so perhaps this was an effort to assist steering an individual in the direction of those who were closer to the customary charges?  Physicians in 2007 were also concerned about a fax campaign used to update their practice information with a fax blasting program used.  Ingenix also provides coding software and books that they sell online as well, so information they are not short of.

Just a few years ago I couldn’t get anyone to hardly listen when I tried to discuss the importance of business intelligence software to do battle with those who have it.  If one is still rummaging through paper files and manually trying to combat transactions they feel are in error that take place in a second with software, it’s a lost cause.  Long and short of it, nobody questions potential errors due to the complexity of manually researching and getting figures so the one side keeps getting fatter.  Perhaps we need some Congressional algorithms at work real soon.  BD 

Sen. Jay Rockefeller, chairman of the Senate Commerce, Science and Transportation Committee, wants answers at a hearing Tuesday from the chief executives of UnitedHealth Group Inc. and its subsidiary Ingenix Inc., a claims database used by insurers nationwide to calculate out-of-network rates.

The inquiry follows lawsuits and an investigation by New York Attorney General Andrew Cuomo alleging that UnitedHealth and Ingenix manipulated rate data so insurers had to pay less and patients more for out-of-network services.  Cuomo's office said Ingenix was understating the market rate for doctor's visits across New York state by 10 percent to 28 percent.

A spokeswoman for Ingenix referred calls to UnitedHealth.

But unknown to many consumers, when patients go out of network, their plan doesn't actually pay 70 percent of the doctor's visit cost. It pays 70 percent of what it determines is the "usual, customary and reasonable" cost for the procedure or doctor's visit in question.

Senate takes on out-of-network insurance issue with Ingenix

Related Reading:

The AMA and the California Medical Association file legal suit – WellPoint and Ingenix

Ingenix Publishes Episode Treatment Groups Methodology – Recreating themselves?
The search for John Doe – Who’s running the queries (Algorithms) and wants to know
Andrew Cuomo – You Have to Like This Guy – Healthcare Reform
Prescriptions risk score used to deny health insurance

Cigna and Aetna face lawsuit – AMA joining the the cause on payment issues

Prescription Data Used To Assess Consumers - No Privacy Unless You Pay Cash...
Americans with Cancer and Insurance Still not able to afford treatments
What is the MIB - Medical Insurance Bureau - and how does it affect qualifying for insurance?
Health Insurance Reserves – How much is in the till, could it be 1 or 2 trillion nationwide?
Health Care Insurers Suggest Algorithms and Business Intelligence solutions to provide health insurance solution
Health insurer accused of overcharging millions – United Health Care/Oxford Insurance 50 Million Fine
Algorithms, Formulas and Investigations leads to AARP suspending sales of some health plans
WellPoint Gets Message from Medicare to suspend 2 Part D programs

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