Out of network health insurance claims and claims paid through indemnity based health plans are settled based on a percentage of the “usual and customary” or “reasonable and customary” charges prevailing in the area where the service is performed. Physicians and patients have long felt that these rates were understated, which leaves patients with a much larger share of healthcare costs than they should actually bear.
Finally NY State Attorney General Cuomo has announced a formal investigation of how these benchmark charges are calculated, and an intention to sue UnitedHealth, Ingenix, and 3 other subsidiaries of United Health over rigging these calculations so that they are intentionally understated.
Examples of how these charges are intentionally understated include:
- Mixing procedures performed by non-doctors with procedures preformed by doctors
- Eliminating high-cost complex cases from the calculation
- Using older data, which bases current allowances on lower costs that existed in prior years
The effect of these and other practices is to understate the true cost so dramatically that a procedure that costs $200 is reported as $77.
There is an extreme conflict of interest, because Ingenix, whose calculations are used by United Healthcare and other insurers as the basis for claims adjudication, is OWNED by United Healthcare. If Attorney General Cuomo is successful, Usual and Customary charges will be calculated by an independent organization.
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that’s why i call it “INGENUINEX”!!
YOU HEARD IT HERE-FIRST!!!
Thank you Mr. Cuomo for taking on this cause. It is amazing we have been putting up with this obsolete and pretentious process. Why hasn’t an independent organization calculated this anyways?
Our organization is exploring the posibility of a class action suit against the “BLUES” and othe health care carriers that we believe conspire with companies as Ingenix and Concentra in order to “low ball” the reimbusements to out of network providers under the pretense that the offer is a percentage “usually and customary.” Are you aware of any pertinent information that would be helpful in supporting our efforts?
Tom Cloud, MPH, Surgical Facility Billing Specialist.
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