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.”

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There’s a lot more going on in health care than mergers (Aetna-Humana, Anthem-Cigna) creating huge players. Hundreds of insurers operate in 50 different states. Self-insured employers, ACA public exchanges, Medicare Advantage, and Medicaid managed care plans crowd an increasingly complex market.

Major health care players are determined to make health information exchanges (HIEs) work. The push toward value-based payment alone almost guarantees that HIEs will be tweaked, poked, prodded, and overhauled until they deliver on their promise. The goal: straight talk from and among tech systems.

They bring a different mindset. They’re willing to work in teams and focus on the sort of evidence-based medicine that can guide health care’s transformation into a system based on value. One question: How well will this new generation of data-driven MDs deal with patients?

The surge of new MS treatments have been for the relapsing-remitting form of the disease. There’s hope for sufferers of a different form of MS. By homing in on CD20-positive B cells, ocrelizumab is able to knock them out and other aberrant B cells circulating in the bloodstream.

A flood of tests have insurers ramping up prior authorization and utilization review. Information overload is a problem. As doctors struggle to keep up, health plans need to get ahead of the development of the technology in order to successfully manage genetic testing appropriately.

Having the data is one thing. Knowing how to use it is another. Applying its computational power to the data, a company called RowdMap puts providers into high-, medium-, and low-value buckets compared with peers in their markets, using specific benchmarks to show why outliers differ from the norm.
Competition among manufacturers, industry consolidation, and capitalization on me-too drugs are cranking up generic and branded drug prices. This increase has compelled PBMs, health plan sponsors, and retail pharmacies to find novel ways to turn a profit, often at the expense of the consumer.
The development of recombinant DNA and other technologies has added a new dimension to care. These medications have revolutionized the treatment of rheumatoid arthritis and many of the other 80 or so autoimmune diseases. But they can be budget busters and have a tricky side effect profile.

Shelley Slade
Vogel, Slade & Goldstein

Hub programs have emerged as a profitable new line of business in the sales and distribution side of the pharmaceutical industry that has got more than its fair share of wheeling and dealing. But they spell trouble if they spark collusion, threaten patients, or waste federal dollars.

More companies are self-insuring—and it’s not just large employers that are striking out on their own. The percentage of employers who fully self-insure increased by 44% in 1999 to 63% in 2015. Self-insurance may give employers more control over benefit packages, and stop-loss protects them against uncapped liability.