A while back, Andrew Cuomo investigated and found the data base to be low imageballing the rates and thus many doctors and patients were under paid on claims, some for about 15 years.  One by one carriers agreed to stop using the data base,  In addition to the lawsuit from the AMA which United Healthcare is in the process of settling there were many more lawsuits filed on the same reasoning, short pays.

Ingenix Data Base Has Some Long Reaching Legal Tentacles with Aetna, Blue Cross, Blue Shield, Humana

Here’s some additional history from 2009.  The new FAIR Database will be the replacement to use when ready. 

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

Its still not over with more lawsuits being filed in may of 2010.  Ingenix is the algorithm and formula division of Untied Healthcare for a number of years they had it going both ways it seems with licensing to other insurers and paying less on claims.

Outpatient Surgery Centers File Class Action Lawsuit Against UnitedHealth and Ingenix for Underpayments

The AMA continues on to say below that Blue Cross may use their own data base with Blue Health Intelligence. 

From the FAIR website:

“FAIR Health, Inc. was established in October 2009 with the mission to help ensure fairness and transparency in out-of-network reimbursement. We are an independent, not-for-profit organization.

The majority of Americans with private health insurance have plans that reimburse for out-of-network care. Under the terms of many of these plans, consumers are reimbursed based on insurer-determined “usual and customary” rates for medical services.  Unfortunately, consumers typically are unaware of what these rates mean or how they are used to help determine reimbursement.  They therefore often do not know how much they will be reimbursed by their insurer when they seek out-of-network care, even though they will be responsible for a portion of the bill they receive from their doctor since that provider has no contract with their insurer. This black box in out-of-network reimbursement information impedes the ability of consumers to make educated and informed health care choices and can be a source of considerable financial anxiety for patients, particularly those with serious illness.

FAIR Health was established in response to New York State Attorney General Andrew Cuomo's investigation into the insurance industry’s methods for determining reimbursement rates for patients who seek care from out-of-network providers. The investigation determined that such reimbursement policies were conflict-laden, potentially flawed, and opaque to patients seeking cost information.  FAIR Health was created to serve as an independent, objective, and transparent source of healthcare reimbursement data for consumers, insurers, healthcare providers, researchers, and policymakers.”

I did a brief look at the website and it is presently still work in progress but there is some initial information available on what is to come.  BD

Physicians are likely to know by this summer how their out-of-network pay will be affected by the organization that was designed to replace UnitedHealth Group-owned Ingenix as the arbiter of "usual, customary and reasonable" payment rates.

The new FAIR Health database, created under agreements with the New York attorney general's office, is set to launch by late January. Payments based on the new figures could be sent to physicians by the summer. In late March, the office plans to unveil a consumer site that will publish typical charges for a given service.

For years, big insurers used databases produced by Ingenix, a UnitedHealth Group subsidiary, to figure out what they would pay out-of-network doctors for care.

In October 2009, the new entity, FAIR Health, was established, and staff started work on the new database within months.

The FAIR Health is expected to first release dental and outpatient data. Other data will be released on a staggered schedule.

Meanwhile, BlueCross BlueShield-affiliated plans filed with the Securities and Exchange Commission in December 2010 to establish its claims database -- Blue Health Intelligence -- as a separate entity from the BlueCross BlueShield Assn. Since 2006, the database has been available only to Blues plans.

FAIR Health will remove the screen previously used by Ingenix to eliminate the highest and lowest charges submitted by providers. In other words, no claim submitted will be excluded from the FAIR Health database solely because it contains charges within the highest or lowest ranges of fees in a geographic area.

FAIR Health will use claims data from the previous five years on a graduated basis proceeding year to year as necessary to reach a 40-observation threshold, adjusting charges from prior years using the consumer price index. If that adjustment yields fewer than 40 observations, FAIR Health will look to a broader geographic area to reach 40 observations or use a regional or national average if that isn't possible.

amednews: New database for out-of-network claims coming soon :: Jan. 24, 2011 ... American Medical News


Post a Comment

Google Analytics Alternative