Mark Meades comments suggest that we assume that Ingenixs rates for out-of-network care are fair. But Ingenix is owned by United HealthCare Services, one of the chief beneficiaries of this assumption! My experience is that the hens best interests are rarely served by only consulting the fox.
Past behavior is generally the best predictor of other past behavior. In California, the Managed Health Care Department has challenged numerous after-purchase policy cancellations by health insurers that assured us that they were only protecting the public from unaffordable healthcare insurance premiums. Sound familiar? The foxes indicated to us that the policy cancellations were the result of egregious misstatements by sickos who had defrauded the insurers, so the retroactive terminations or care denials were justified.
Then we learned that health-plan employees were being paid bonuses to terminate policies by using 20-20 hindsight underwriting to concoct theories of underwriting denials. Buyers were provided with vaguely worded applications open to multiple interpretations and allowed to believe that they were insured, only to have the insurance sleuths be paid to yank their coverage retroactively for real or imagined misstatements. Financially strapped, very sick people were left to fend for themselves, as they were buried by mountains of debt or denied potentially lifesaving care.
These egregious acts came to light because of policyholder litigation. The Ingenix controversy should be handled in the same manner, so both sides can have their positions examined and a fair outcome determined by a more impartial body than Ingenix. For consistency and affordability, the case should be certified for class-action status.
Health insurance plays an important role in the efficient delivery of healthcare. Insurers are not the guarantors of all calamities that may befall an insured, but they must be held accountable to provide for the risks that they accepted in issuing the policy. In the Ingenix case, the attorney general asserts that an extra premium was charged by United to provide out-of-network coverage on an 80-20 split with the insured, based on the lower of the doctors full bill or the reasonable or customary rate. In an example cited by the attorney general, a billing of $200 would result in a resetting of the reasonable and customary rate to $77, and United would reimburse the insured $62. The patient is left with a $138, or a 69% share, vs. the 20% share or $40 amount they claim to have been entitled under the language in the policy.
If asked to pick between health insurance and the plaintiffs bar from an ethics perspective, I would be stumped. Both, however, have their place in protecting the public.
Michael WhiteLos Angeles To submit a letter to YOUR VIEWS, click here. Please include your name, title and hometown.