Rockefeller challenges UnitedHealth's out-of-network rates

Sen. Jay Rockefeller (D-WV) is expected to challenge the out-of-network pricing practices of UnitedHealth Group and its claims subsidiary, Ingenix at a Senate hearing scheduled for Tuesday.

Rockefeller's inquiry follows an investigation conducted by New York Attorney General Andrew Cuomo's office. Cuomo claims that UnitedHealth and Ingenix manipulated rate data so insurers would pay less and patients would be on the hook for a larger share of out-of-network service fees. 

"They're low-balling deliberately. They deliberately cut the numbers so the consumer has to pay more of the cost," Rockefeller said. "It's scamming. It's fraud."

According to Cuomo's investigation, UnitedHealth and Ingenix, allegedly manipulated claims data to calculate and define "usual, customary and reasonable" costs--paid by the insurer. Ingenix was understating the market rate for doctor's visits across New York state between 10 and 28 percent, according to Cuomo. 

Last year, the American Medical Association and others sued UnitedHealth for overcharging consumers for out-of-network treatment. In January, to settle the suit, UnitedHealth agreed to pay $350 million, although the insurance giant admitted no liability. The company also agreed to fund a new independent claims database that would render its closely held commercial claims database, Ingenix, obsolete. 

The AMA, consumer advocacy lobbies and a number of legislators are keeping the fight alive, insisting on greater transparency for out of network claims policies throughout the industry. The Associated Press reports that the AMA and other lobbies plan to file similar suits over out-of-network claims practices--against other major carriers including Cigna, WellPoint and Aetna.

Rockefeller plans to question UnitedHealth and Ingenix at Tuesday's hearing to better understand how they calculated so called "usual, customary and reasonable costs" for out-of-network claims. More than 70 percent of workers receiving healthcare through their employers are enrolled in plans that permit out-of-network care, according to the Kaiser Family Foundation.

For more:
- see the Associated Press story
- here's more about the hearing

Suggested Articles

The profit margins and management of Community Health Group raise questions about oversight of managed care insurers.

Financial experts are warning practices about the pitfalls of promoting medical credit cards to their patients.

A proposed rule issued by HHS on Tuesday would expand short-term coverage, a move Seema Verma said will have "virtually no impact" on ACA premiums.