It would be nice if all the analytics worked equally but it appears they don’t. We have all heard the stories about the folks needing services getting claims denied or small portions paid but in this case with their particular surgical facility the insurers missed the cost analytics it appears and now have filed suit against them. Below is a link to where doctors who are on the other side suing Aetna for non payment of out of network charges, so we have insurers suing doctors and doctors suing insurers out there today.
California Doctors Sue Aetna For Routinely Denying Out of Network Patient Access–Grading on the Curve Algorithms Versus Individual Patient Assessments?
I have had doctors tell me too that an insurer pays a claim and then later does an audit, and makes the adjustment on the next check they send out with a debit. The problem with this is that the claims the check covers usually has no reference to the claim where the insurer recoups the money and it becomes a bit of an accounting nightmare. Why is there mistrust in this area? Well it probably goes back to the old United (Ingenix) lawsuit that was settled where doctors and patients were short paid for 15 years on out of network services. The two links below have some back information on this as almost every major insurer used the Ingenix data base to calculate.
Ingenix Data Base Has Some Long Reaching Legal Tentacles with Aetna, Blue Cross, Blue Shield, Humana It has now been replaced by a non profit company, the FAIR data base and one might wonder if Aetna and United are using it? I would think it would be logical to do so, right?
New FAIR Data Base Slated to Be Available Later this Year To Replace the Corrupted Data Base Used by Ingenix to Calculate Out of Network Insurance Charges
We also have other lawsuits relative to the same issue outside of the AMA lawsuit.
Outpatient Surgery Centers File Class Action Lawsuit Against UnitedHealth and Ingenix for Underpayments
Gosh it is no wonder we can’t trust some of the analytics running out there today and hopefully the FAIR data base might be eliminating some of the flawed data floating around out there if insurers are using it. Due to the complex medical billing system we have there will be one story after another as everyone is looking at fine tuning their analytics to get every last penny which is ok, but the existence of lawsuits and all that additional expense does little for the patients today who need care and the increasing activity and focus in many of these areas tend to take away from this.
Again with the Ingenix algorithms that for 15 years allowed short pay on out of network charges, it’s no wonder doctors don’t trust all the information given by insurers and hesitate strongly on accepting some of their contracts as there’s a lot of gray out there. BD
The insurers' lawsuits are aimed at a firm named Bay Area Surgical Management. BASM's business model is the sale of shares in its half-dozen Northern California outpatient surgery clinics to doctors, who agree to perform at least a third of their surgeries at the facilities.
To the extent that the clinics don't have contracts with major insurers that specify how much they'll get paid for each procedure, they can charge whatever the market will bear.
What bugs Aetna is that some of the physician share owners are members of Aetna's network, which helps the doctors attract patients. The insurer's position is that when the doctors refer those patients for surgeries or tests to out-of-network facilities they themselves own, that defeats the purpose of building a network based on negotiated fees.
The idea is to encourage patients to use network providers who accept negotiated fees, which saves everyone money. The Aetna and United lawsuits say the BASM clinics winked at the patient obligations by waiving the coinsurance charge and promising not to bill patients for any balance not covered by their insurers. They then allegedly filed sky-high claims with the insurers, hoping to be reimbursed for the whole sum.
The insurers say that what they're really concerned about is fraud. Aetna and United maintain that BASM never actually planned to charge the patients the amounts they submitted to insurers — the clinics told patients that they would accept in full settlement of their bills whatever the insurers decided to pay. In filing the higher claims, Aetna and United say, the clinics were crossing their fingers that the insurers wouldn't examine them too carefully before paying.
Yet they say they got snookered to the tune of $60 million by BASM's surgery centers. The insurers don't have a good explanation for why they didn't catch this alleged fraud and put a stop to it long ago — or why they paid what they now say were manifestly inflated claims.