Tuesday, January 13, 2009

Cuomo Shows the Health Insurance Indusry Who's Boss!!

New York Attorney General Andrew Cuomo today announced a "victory" in his battle with the insurance industry over how out-of-network physician claims are paid. Cuomo had argued that the industry's use of its out-of-network "customary and reasonable" database "defrauded" consumers and he sued the database's manager, United Health's Ingenix, over the controversy.

In a February 2008 post I said, "In a few months, we will hear that Ingenix paid a big fine and agreed to fix something (that no one will understand) and Cuomo will have another notch in his belt."

Well, today it was announced that Ingenix will pay $50 million to set up an independent not-for-profit to operate the customary and reasonable database. The industry gets to continue determining what customary and reasonable physician charges are through this non-profit and just exactly how they do it will continue to be done by systems gurus the way systems gurus do things--pretty much in a "black box." While an undetermined university will operate the system, the industry, who will finance it, will presumably have a great deal of input into it. The industry's use of the database will be more defensible since one of its own is no longer arguably directly controlling the entity.

$50 million is peanuts compared to the out-of-network customary and reasonable savings any one of the big health plans achieves every year and this settlement makes the ability of state medical societies and trial lawyers to attack the system much harder.

What will be better is that consumers, presuming they know about the new "transparency" website, will be able to go on-line to see what their allowable charges will be in advance. So, if Joe MiddleAmerica is on vacation in Orlando and needs to go out-of-network to the emergency room, prior to rushing off for treatment they can go find a computer, find the website, and shop around for emergency rooms that have the lowest out-of-network payments. Gosh, Andy, thanks!!!

The big losers here are the docs. The result is going to be about the same and their medical societies will now have less reason to challenge the customary and reasonable system than they did before.

"In a few months, we will hear that Ingenix paid a big fine and agreed to fix something (that no one will understand) and Cuomo will have another notch in his belt."

Why poor Andy is being passed over for the Senate I just don't know!

Earlier posts:
Give Cuomo and the Physicians What They Say They Want--Show the Patient Just What the Doc Is Accepting From Everyone Else

The Usual and Customary Controversy--Who's Cheating Whom?

No One Ever Did Understand "Customary and Reasonable"
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