New York Attorney General Andrew Cuomo has picked up a battle that the American Medical Association has waged for nearly eight years without success: taking down Ingenix, the UnitedHealth Group subsidiary that most insurers rely on to crunch reimbursement rates for out-of-network providers.
Last week, Cuomo announced at a news conference his intent to sue Ingenix, Eden Prairie, Minn., and UnitedHealth, Minnetonka, Minn., alleging that the Ingenix database is both flawed and intentionally manipulated to yield low-ball estimates for what's usual, customary and reasonable, or UCR, to charge for any given service in a geographic area. The head of Cuomo's healthcare industry task force, Linda Lacewell, bluntly called Ingenix "nothing more than a conduit for rigged information that is defrauding consumers of their right to fair payment."
Cuomo might succeed even though the AMA has gotten virtually nowhere with a lawsuit still pending in U.S. District Court in New York City, potentially ending the days of patients expecting insurers to cover the bulk of an out-of-network bill only to find the reimbursement doesn't reflect what the providers really chargeand leaving the patient to pay the balance.
The American Hospital Association also is interested in what Cuomo's investigation turns up. "We hope the attorney general is looking into reimbursements to patients for out-of-network hospital care," spokeswoman Elizabeth Lietz said.
Edward Shaya partner at the law firm Post & Schell in Philadelphia who specializes in health IT and represents providers in their relationships with payerssaid Cuomo wont be mired in the same kind of "preliminary skirmishing" engaged in for so long by the AMA and its partner plaintiffs, which include the Medical Society of the State of New York, beneficiaries of various plans connected to UnitedHealth and physicians.
"The seven years of dodge ball between the plaintiffs and the defense is no longer the name of the game," Shay said. Cuomo's office "can get things that private litigants couldn't get after seven years. They can find out what's in the charge database. How is it collected? When was it last updated?"
Indeed, Cuomo just proved his strength against insurers with a victory regarding physician rankings that he complained were based more on cost than quality. UnitedHealth along with Aetna, Cigna Corp. and Empire Blue Cross and Blue Shield last year signed agreements with Cuomo's office promising their rankings would be transparent and tied to nationally recognized quality benchmarks.
After Cuomo announced his Ingenix investigation Feb. 13, UnitedHealth issued a written statement saying the company is cooperating with his office and disputing his characterization of the database: "The reference data is rigorously developed, geographically specific, comprehensive and organized using a transparent methodology that is very common in the healthcare industry."