Managed Care - February 2009 - (Page 7) NEWS AND COMMENTARY Who Will Benefit From Ingenix Settlement? ew York Attorney General Andrew M. Cuomo reached an agreement with UnitedHealth Group, the nation’s second largest insurer and owner of the Ingenix databases that are used by most of the nation’s insurers and third-party administrators to determine payments for out-ofnetwork care. What drew the AG’s ire was the “usual, customary, and reasonable” reimbursement rates reported by the database company. Cuomo contended that the company had engaged in a “scheme to defraud consumers” by systematically underpaying patients by hundreds of millions of dollars over the last decade. Under the terms of the agreement, the database of billing information operated by Ingenix will close. UnitedHealth agreed to pay $50 million to a not-for-profit organization that will establish a new, independent database to help determine fair outof-network reimbursement rates for consumers. In a separate agreement, Aetna will pay $20 million to help maintain the new database. UnitedHealth and Aetna contributed 70 percent of the billing information that made up the Ingenix database. “Health insurers will no longer be able to distort their data, leaving patients with unfair bills,” says Cuomo. Experts on benefits say that if the agreement results in higher payment rates for doctors, as is expected, selfinsured employers will see their portion of out-of-network payments grow, while employers with fully insured plans will probably see their premiums increase as insurers pass on their increased costs. Cynthia Michener, a spokeswoman for Aetna, says the company will not look to managed care organizations or health insurers to help pay for the costs to maintain the database by the not-for-profit company. The new database will only be used for out-of-network claims for health plans that define the benefit in terms of “prevailing charge” or UCR charge. Joe Paduda, principal of Health Strategy Associates, a consulting company, and author of the health blog “Managed Care Matters,” says it is too early to tell how this settlement will affect insurers. He points out on his blog that “providers that are paid by UCR will find it much easier to challenge the amount they are reimbursed.” N Obama Rescinds MA Letter With the Obama administration moving quickly to take the reins at Medicare, officials recalled a draft of the 2009 Medicare Advantage and Part D call letter, signaling that changes are probable. “Some of the Medicare advocates as well as folks on the Hill like California Democrat Pete Stark have called on the Obama administration to rescind it and put their own stamp on it,” says Paul Precht, director of policy and communications at the Medicare Rights Center. “We want to ensure that benefits provided by Medicare Advantage plans provide adequate financial protection, are easier to understand, and are transparent for the consumer.” Some cost-sharing techniques that can prove a nasty surprise for members are likely to be at the top of the list of upcoming changes, which would be put in place for 2010. “We’ve seen plans with out-ofpocket limits that exclude certain services,” adds Precht. “Sometimes we find out those services are Part B drugs, which includes chemotherapy. We would want language to say more definitely that that type of arrangement is not acceptable.” The letter also provoked a quick cheer from Pete Stark, the chairman of the House Ways and Means Health Subcommittee and a longtime critic of Medicare Advantage. “This letter would have locked in another year of lax Bush-era guidelines for private insurers in Medicare, and I am pleased that the Obama administration rescinded this letter,” he said in a statement. Medicare Advantage plans should not have long to wait to find out exactly what the new administration has in mind. “We recognize that MA organizations and PDP sponsors need to have 2010 guidance available in order to prepare their bids by the statutory deadline, and therefore [we] will post a draft reflecting any changes resulting from a review of the current draft as soon as possible,” CMS said. ICD-10 Delayed For Two Years Managed care companies generally welcomed the news last month that the deadline for implementing ICD10 codes had been pushed back by two years. The transition must now occur by Oct. 1, 2013, according to a final reg- FEBRUARY 2009 / MANAGED CARE 7
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