Who Will Benefit From Ingenix Settlement?

New York Attorney General Andrew M. Cuomo reached an agreement with UnitedHealth Group, the nation’s second largest insurer and owner of the Ingenix databases that are used by most of the nation’s insurers and third-party administrators to determine payments for out-of- network care.

What drew the AG’s ire was the “usual, customary, and reasonable”  reimbursement rates reported by the database company. Cuomo contended that the company had engaged in a “scheme to defraud consumers” by systematically underpaying patients by hundreds of millions of dollars over the last decade.

Under the terms of the agreement, the database of billing information operated by Ingenix will close. UnitedHealth agreed to pay $50 million to a not-for-profit organization that will establish a new, independent database to help determine fair out-of-network reimbursement rates for consumers.

In a separate agreement, Aetna will pay $20 million to help maintain the new database. UnitedHealth and Aetna contributed 70 percent of the billing information that made up the Ingenix database.

“Health insurers will no longer be able to distort their data, leaving patients with unfair bills,” says Cuomo.

Experts on benefits say that if the agreement results in higher payment rates for doctors, as is expected, self-insured employers will see their portion of out-of-network payments grow, while employers with fully insured plans will probably see their premiums increase as insurers pass on their increased costs.

Cynthia Michener, a spokeswoman for Aetna, says the company will not look to managed care organizations or health insurers to help pay for the costs to maintain the database by the not-for-profit company.

The new database will only be used for out-of-network claims for health plans that define the benefit in terms of “prevailing charge” or UCR charge.

Joe Paduda, principal of Health Strategy Associates, a consulting company, and author of the health blog “Managed Care Matters,” says it is too early to tell how this settlement will affect insurers. He points out on his blog that “providers that are paid by UCR will find it much easier to challenge the amount they are reimbursed.”