Out of Network Rate Setting in the Post-Ingenix Environment

Early in 2009, the New York State Office of the Attorney General reached settlements with several large health insurers that require them to replace their use of the Ingenix PHCS (R) database to establish out of network UCR payment rates.  The settlement requires the use of a new database that has not yet been developed.  Although the settlements identify the requirements for insurer action, several technical and implementation questions remain unanswered.  This paper explores some of those questions and describes an alternate solution for out of network payment.