If you have kept up here on the site of late, there’s been quite a bit posted about Ingenix.  The related reading below will catch you up.  What is Ingenix, health insurance business intelligence in short.  This is why you may hear me talk and recommend business intelligence software for hospitals and healthcare organizations, so you know what is going on at the other end when it comes to reimbursements.  Without a data solution that can help you analyze what is going out, where it’s going, and more important what is coming in and how much with a few clicks of a mouse with a nice dashboard with some real time figures, you’re stuck in a long process to cumulate and present all this information in a useable format any many don’t have the time nor the money to spend to manually gather and analyze the information, so the health insurance industry has been hedging all along on this factor to be blunt. 

They have the algorithms and much of healthcare has not, so they got the money in short.  The Medical Association of Georgia has also joined the cause with the suit filed by the AMA.  The California Nurses Association today also blasted the offer made by insurers to not hike rates for patients based on pre-existing conditions as it will still maintain the other qualification procedures that will pretty much do the same for analytical purposes.   This post is also good reading, we don’t want to be fooled again, and need the “smart people” in key positions.

Madoff's Scheme – One Reason To Put the “Smart People” in the Right Places So We Don’t Get Fooled Again

Once more it’s the algorithms and whistleblowers that are the two hottest trends in healthcare, and I am glad we are finding some “smart”whistleblowers that know what the algorithms and formulas are and how they create transactions, Andrew Cuomo for one.  Ingenix also used medication profiles to run their complex formulas as well from prescription data and last year had profits of 1.3 billion.  The quote below is from an earlier post in August of 2008 and states the drug profiles are much easier to get and take less time than having to get the records from a physician.  

"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.”

Prescriptions risk score used to deny health insurance

Hopefully we will see some good results with some of the “smart people” finally offering a challenge to those who have ruled with all the formulas and algorithms and we as a nation and our government can finally stop functioning like a PC with no anti-virus protection and rid ourselves of all the “root kits” that have turned us all into zombies.  BD  

Anthem Blue Cross of California parent WellPoint Inc. colluded with database firm Ingenix to fix prices in a multistate scheme to underpay doctors for so-called out-of-network medical care, physician organizations contended in a lawsuit filed Wednesday. 
The American Medical Assn., the California Medical Assn. and other state medical organizations said in the suit filed in federal court in Los Angeles that the scheme cost physicians millions of dollars and resulted in patients paying more than they should have.

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)
Indianapolis-based WellPoint said in a statement that it was committed to providing appropriate reimbursement for out-of-network services. The company said it was reviewing the suit and had no further comment.

Earlier this year, Minnetonka, Minn.-based UnitedHealth agreed to shut down the database. In exchange, New York Atty. Gen. Andrew Cuomo dropped an investigation. Cuomo had accused Ingenix of cheating patients by using faulty data to reduce out-of-network payments.

Doctors groups allege WellPoint's collusion cost them millions - Los Angeles Times

Related Reading:

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
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?
Will Greed lead to Meltdown of the Health System?
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
Algorithms, Formulas and Investigations leads to AARP suspending sales of some health plans


  1. Insurance, in law and economics, is a form of risk management primarily used to hedge against the risk of a contingent loss.
    Basically it means as a equitable transfer of the risk of a loss, from one entity to another, in exchange for a premium, and can be thought of as a guaranteed small loss to prevent a large, possibly devastating loss.the insurer is the company who is selling the insurance policy and the insured is the person who takes that policy.The insurance rate is a factor used to determine the amount to be charged for a certain amount of insurance coverage, called the premium.there are various types of insurance such as:-

    1. house insurance

    2. car insurance

    3.human insurance called as medicare

    4.shop insurance
    and so on.

    i mean to say that at present world atleast in all fields the insurance companies will provides this insurance facility to secure our property in the cricis.the insurance also protects our spent money in some field by providing their required amount of our damage property.if we claim for our damage property the insurance company will provide the required price of that property at present time.it's property i am talking about it covers all those things for which we takes the insurance policies.

    here below i tell you about some losses and their premium and how the losses are calculated, so take a look on that:-
    # Definite Loss. The event that gives rise to the loss that is subject to the insured, at least in principle, take place at a known time, in a known place, and from a known cause. The classic example is death of an insured person on a life insurance policy. Fire, automobile accidents, and worker injuries may all easily meet this criterion. Other types of losses may only be definite in theory. Occupational disease, for instance, may involve prolonged exposure to injurious conditions where no specific time, place or cause is identifiable. Ideally, the time, place and cause of a loss should be clear enough that a reasonable person, with sufficient information, could objectively verify all three elements.
    # Accidental Loss. The event that constitutes the trigger of a claim should be fortuitous, or at least outside the control of the beneficiary of the insurance. The loss should be ‘pure,’ in the sense that it results from an event for which there is only the opportunity for cost. Events that contain speculative elements, such as ordinary business risks, are generally not considered insurable.
    # Large Loss. The size of the loss must be meaningful from the perspective of the insured. Insurance premiums need to cover both the expected cost of losses, plus the cost of issuing and administering the policy, adjusting losses, and supplying the capital needed to reasonably assure that the insurer will be able to pay claims. For small losses these latter costs may be several times the size of the expected cost of losses. There is little point in paying such costs unless the protection offered has real value to a buyer.
    # Affordable Premium. If the likelihood of an insured event is so high, or the cost of the event so large, that the resulting premium is large relative to the amount of protection offered, it is not likely that anyone will buy insurance, even if on offer. Further, as the accounting profession formally recognizes in financial accounting standards, the premium cannot be so large that there is not a reasonable chance of a significant loss to the insurer. If there is no such chance of loss, the transaction may have the form of insurance, but not the substance. (See the U.S. Financial Accounting Standards Board standard number 113)
    # Calculable Loss. There are two elements that must be at least estimable, if not formally calculable: the probability of loss, and the attendant cost. Probability of loss is generally an empirical exercise, while cost has more to do with the ability of a reasonable person in possession of a copy of the insurance policy and a proof of loss associated with a claim presented under that policy to make a reasonably definite and objective evaluation of the amount of the loss recoverable as a result of the claim.



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