Insurance reimbursement rates likely won't rise despite UnitedHealth settlement Insurance reimbursement rates likely won't rise despite UnitedHealth settlement
19/01/09 17:22
UnitedHealth, along with other health plans and employers, used Ingenix’s databases to help determine the “usual and customary” payment rates for medical services outside their network of hospitals and physicians. Because UnitedHealth owned Ingenix and provided health coverage, database managers had a strong incentive to keep payments low, New York Attorney General Andrew Cuomo has said.
Local health-care experts, however, already question the new nonprofit’s independence.
No third-party entity could call itself independent after receiving millions of dollars from the industry it was designed to regulate, said Brian Klepper, a health-care consultant based in Jacksonville.
The new nonprofit will share information not only with insurers but also the general public. A Web site will inform consumers of the out-of-network reimbursement in their area for common medical services — a service Klepper criticized as having “pretty limited use.”
“If you are out of town and you need to go to an emergency room, you can go to a computer and see what hospitals have reasonable rates,” Klepper said.
Out-of-network visits tend to arise from out-of-town emergencies or having to see a specialist, such as a dermatologist. Providers generally charge more for such visits, and insurers agree to pay about 80 percent of what they see as the fair market price — not what the patient was actually charged.
Cuomo’s investigation found that patients were shortchanged by up to 28 percent for various medical services through “faulty data collection, poor pooling procedures and [a] lack of audits,” his office said in a statement.
The American Medical Association called the settlement a “giant step” toward increasing transparency in the health-insurance industry. But at least one local physician remains skeptical that the new database system will lead to reform.
“I think the companies they set up are beholden one way or the other to the mother company,” said Jacksonville neurologist Jacob Green.
Harvey Matoren, president and CEO of Jacksonville-based Claims Security of America, which assists in filing health-insurance claims, said the UnitedHealth case illustrates the problems inherent in the reimbursement system.
“This is not an isolated incident,” Matoren said. Because of wide disparities between the charge and the actual cost of medical services, “the system really doesn’t work to the patient’s advantage.”
UnitedHealth, in a class-action suit, agreed last week to pay $350 million to its health plan members and out-of-network providers for procedures dating back to 1994.
Potential recipients will be notified in writing and through advertising, spokesman Don Nathan said. An allocation plan is to be determined in court.
Local health-care experts, however, already question the new nonprofit’s independence.
No third-party entity could call itself independent after receiving millions of dollars from the industry it was designed to regulate, said Brian Klepper, a health-care consultant based in Jacksonville.
The new nonprofit will share information not only with insurers but also the general public. A Web site will inform consumers of the out-of-network reimbursement in their area for common medical services — a service Klepper criticized as having “pretty limited use.”
“If you are out of town and you need to go to an emergency room, you can go to a computer and see what hospitals have reasonable rates,” Klepper said.
Out-of-network visits tend to arise from out-of-town emergencies or having to see a specialist, such as a dermatologist. Providers generally charge more for such visits, and insurers agree to pay about 80 percent of what they see as the fair market price — not what the patient was actually charged.
Cuomo’s investigation found that patients were shortchanged by up to 28 percent for various medical services through “faulty data collection, poor pooling procedures and [a] lack of audits,” his office said in a statement.
The American Medical Association called the settlement a “giant step” toward increasing transparency in the health-insurance industry. But at least one local physician remains skeptical that the new database system will lead to reform.
“I think the companies they set up are beholden one way or the other to the mother company,” said Jacksonville neurologist Jacob Green.
Harvey Matoren, president and CEO of Jacksonville-based Claims Security of America, which assists in filing health-insurance claims, said the UnitedHealth case illustrates the problems inherent in the reimbursement system.
“This is not an isolated incident,” Matoren said. Because of wide disparities between the charge and the actual cost of medical services, “the system really doesn’t work to the patient’s advantage.”
UnitedHealth, in a class-action suit, agreed last week to pay $350 million to its health plan members and out-of-network providers for procedures dating back to 1994.
Potential recipients will be notified in writing and through advertising, spokesman Don Nathan said. An allocation plan is to be determined in court.