Two US health insurers have agreed to pay tens of millions of dollars to create independent claims rates databases, following an investigation into claims that databases had been rigged to manipulate payments.
United Healthcare last week last week agreed to pay $350 million to settle three class-action lawsuits claiming the company rigged a database used to determine payment rates.
UnitedHealth agreed to settle an investigation by New York State Attorney General Andrew Cuomo that claimed health insurers understated the portion of reimbursements for which they are responsible for such services by as much as 28% in some cases, or hundreds of millions of dollars over the last 10 years.
UnitedHealth admitted no liability in settling the three class-action lawsuits filed by physicians and health plan members over the payment database for out-of-network medical services.
According to US press reports under the agreement with Cuomo, UnitedHealth will pay €32 ($50) million to finance the development of a new database that will be operated independently by a yet to be determined university.
Ingenix, a subsidiary of UnitedHealth, operates the Prevailing Healthcare Charges System, a database used by most health insurers that determines the "usual and customary rates". The Ingenix database contains information on more than one billion claims from more than 100 health insurers.
Health insurers pay for a certain percentage of the usual and customary rates for such services, based on an estimate of the cost for such procedures in the same geographic area, this is used to help calculate the reimbursement an insurer then pays to providers or members.
UnitedHealth Group, one of the largest US insurers, uses the same schedules as a basis for reimbursing consumers.
The New York Attorney General said that this "gives Ingenix an incentive to manipulate the data so as to reduce reimbursement rates". He said that other health insurers that use Ingenix have the same conflict of interest.
According to Coumo "With the creation of a new, independent database, consumers can now look forward to having more information, greater clarity and fundamental fairness in the out-of-network reimbursement system".
In a separate deal reached with Coumo, the third largest health insurer, Aetna, will pay €13 ($20) million to a qualified non-profit organisation that will establish a new, independent database to help determine fair out-of-network reimbursement rates for consumers throughout the United States