A crop of lawsuits highlights the difficulty of determining reasonable provider payment rates. Providers will always want higher reimbursements while insurance companies aim to pay the least amount possible. Unfortunately for consumers, when you are using out of network providers you may get stuck in the middle.
Many insurers use the Ingenix pricing guide to determine “customary” fees. The Ingenix guide is ultimately owned by United. It seems to work well for the insurers; maybe not for providers and consumers. Thus the lawsuits.
AMA sues UnitedHealth – Settlement $350M - The AMA and others claimed that UnitedHealth underpaid physicians and shortchanged consumers when paying out of network claims.
AMA is now suing both Cigna and Aetna on similar claims.
New York AG Andrew Cuomo settles with UnitedHealth- Settlement $50M – This settlement will be used to build a public database to track provider fees and ultimately United will discontinue the Ingenix pricing products in this area.
New York AG Andrew Cuomo settles with Aetna- Settlement $20M- Aetna settlement contributes to the development of the public database and will stop using the Ingenix pricing databases.
Reports state that Cuomo has subpoenaed Cigna, WellPoint and others. No settlements or resolution yet on those.
We’ll keep a watch out for additional settlements, the development of the public database and how this may help consumers.
update 2/18/09: New York AG Andrew Cuomo settles with Wellpoint - Settlment $10M - Wellpoint now joins other larger insurers by paying $10M to the yet to be created nonprofit database company.
WellPoint’s subsidiary Empire BlueCross Blue Shield (“Empire”) is the largest health insurer in New York State, with approximately five million members.
The Nonprofit database company has yet to be selected or announced. We'll stay tuned.
Sunday, February 15, 2009
Wednesday, February 4, 2009
Physician Medicare Data Will Not Be Transparent
An appeals court just rejected a request to allow disclosure of Medicare data related to physician services. This is not a helpful ruling for those interested in increasing transparency of quality and costs in healthcare.
The Doctors: The American Medical Association representing the doctors asserts that doctors have a right to privacy so the data should remain private. And by the way, the information isn't perfect, so we wouldn't want to confuse consumers with information they probably can't understand.
The Government: The government has made many statements and taken actions to increase transparency (the new administration as upped the volume on 'open government'), yet Health and Human Services - HHS- stood in opposition to disclosure of this information. This is in contrast to their use of Medicare data disclosures for hospitals which they provide here.
The Judges: The lower court had ruled for disclosure of the information. The new court ruled that freedom-of-information laws are mainly intended to shed light on government operations, not the workings of private businesses. The government spends billions of dollars on healthcare services representing one of the larger and faster growing portions of the overall budget. It is hard to miss the connection to the government's operations.
Next Steps: The nonprofit Consumers' Checkbook group who brought the case is considering an appeal.
When a person contracts with the government, they might expect the terms of those dealings to be made open to the public. If a physician accepts payment from the public, does the public have a right to know about those payments? And do we really think information must be perfect before we disclose it? Do we want our government deciding which information we should get?
Unfortunately, the ruling goes against the trends towards increased transparency in healthcare. Let's hope the issue doesn't end here.
The Doctors: The American Medical Association representing the doctors asserts that doctors have a right to privacy so the data should remain private. And by the way, the information isn't perfect, so we wouldn't want to confuse consumers with information they probably can't understand.
The Government: The government has made many statements and taken actions to increase transparency (the new administration as upped the volume on 'open government'), yet Health and Human Services - HHS- stood in opposition to disclosure of this information. This is in contrast to their use of Medicare data disclosures for hospitals which they provide here.
The Judges: The lower court had ruled for disclosure of the information. The new court ruled that freedom-of-information laws are mainly intended to shed light on government operations, not the workings of private businesses. The government spends billions of dollars on healthcare services representing one of the larger and faster growing portions of the overall budget. It is hard to miss the connection to the government's operations.
Next Steps: The nonprofit Consumers' Checkbook group who brought the case is considering an appeal.
When a person contracts with the government, they might expect the terms of those dealings to be made open to the public. If a physician accepts payment from the public, does the public have a right to know about those payments? And do we really think information must be perfect before we disclose it? Do we want our government deciding which information we should get?
Unfortunately, the ruling goes against the trends towards increased transparency in healthcare. Let's hope the issue doesn't end here.
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