Managed Care - February 2009 - (Page 15) sidiary, is one of the nation’s largest providers of health care billing information. Some of the country’s best known health insurers contribute to the Ingenix database and also use it to calculate payments for out-of-network claims that are based on a community’s usual, customary, and reasonable (UCR) charges. The issue is the calculation of UCR charges. Claimants, such as the American Medical Association in an ongoing lawsuit that began in 2000, charge that United and its subsidiaries use artificially low figures to calculate the UCR rate so as to force patients to take on a higher share of the costs. In turn, patients accuse physicians and hospitals of overcharging to compensate for lower rates that are part of the providers’ contracts with other health plans, and that sometimes leads to balances remaining unpaid and impairment of relationships between patients and providers. For example, if a patient with out-of-network benefits sees an outof-network physician who charges $200 for a visit, the carrier may report the typical UCR rate in the community as $75 and pay 80 percent of the $75, leaving the insurer to pay $60 and the patient, $140. Patients and providers charge that the UCR is calculated improperly, and that the UCR fee could, in fact, be $150, so the carrier should pay $120 “There are only so many $100 million settlements a company can sustain,” and the patient $80. says Steven Ziegler, JD, a lawyer who defends some of the biggest health care The Ingenix database is not an acplans in the industry. curate representation of UCR rates, according to a January 2008 finding by the appelmillion; 35 BCBS plans and the BCBS Association, late division of a Massachusetts State District Court $128 million; Cigna, $440 million; and WellPoint, in a decision in favor of a chiropractor in Michael $498 million. Davekos P.C. v. Liberty Mutual Insurance Co. Liberty used Ingenix data to determine what it Ingenix would pay Davekos. The case has been sent to a trial While this so-called multidistrict litigation case court. is basically over, a new tidal wave of “Ingenix” class In addition, in a New Jersey class action case setaction lawsuits threatens to produce similarly large tled in 2007, McCoy, et al. v. Health Net, et al., the settlements. Ingenix, a UnitedHealth Group sub- FEBRUARY 2009 / MANAGED CARE PHOTOGRAPH BY BRIAN TIETZ 15
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