If you thought you weren’t getting enough reimbursement from the Empire Plan when you used non-participating doctors or other health providers, you might be right.
New York State Attorney General Andrew Cuomo called it fraud. He has ordered United HealthCare (UHC) to overhaul the Reasonable and Customary (R&C) Charge databases it uses to determine how much to reimburse an enrollee who has used a non-participating provider.
Ingenix, a subsidiary of UHC, controls the databases used by UHC. Many other health insurance carriers also use Ingenix databases to pay claims.
The Attorney General’s office said, by using these databases, the health insurance industry had engaged in “a scheme to defraud consumers” by systematically underpaying patients.
A one-year investigation found the data had understated the true market rates of medical care by as much as 28 percent.
The order to overhaul the R&C databases is part of a settlement between the attorney general and UHC. It requires the creation of a new, independently operated database, to be run by a university to be determined. UHC will pay $50 million to create the new database. In the interim, Ingenix is allowed to continue operating. No criminal charges have been sought in the case, nor was UHC required to pay restitution to consumers.
“Although some reimbursements will go up under this settlement, you still may experience very high out-of-pocket costs when using non-participating providers,” said PEF Director of Contract Administration Robert Carrothers.
“Participating providers remain by far the most economical choice for Empire Plan enrollees,” he said. “A copayment is the most they will cost you.
However, when you use non-par providers, you must satisfy a deductible and pay coinsurance, plus the balance of the provider’s charge exceeding the R&C reimbursement.
