Good news for those having problems with their insurance companies

[Lani]

who use artifically low "usual and customary" levels to decide what to reimburse:
Cancer patient gains one crucial victory in fight against insurance company
[New York Daily News]
When Mary Jerome was diagnosed with ovarian cancer nearly three years ago, she knew she was in for the fight of her life.
She just didn't know that fight would also be against her health insurance company, Oxford.
"I felt victimized - and extremely angry," said Jerome, 64, of Yonkers, who teaches English at Columbia University. "The anxiety and fear I felt, it was almost as much as I felt when I got the diagnosis.
"It was almost too much to bear," she said.
Jerome - who chose to be treated out-of-network at Memorial Sloan-Kettering Cancer Center - estimates that she owes as much as $70,000 for her medical care, including chemotherapy treatments.
Her insurance company decided through Ingenix, the nation's largest provider of health care billing information, that many of her treatments, including a number of her medications, were not covered. She wrote a letter to Attorney General Andrew Cuomo to complain.

Attorney General Cuomo Announces Historic Nationwide Health Insurance Reform; Ends Practice Of Manipulating Rates To Overcharge Patients By Hundreds Of Millions Of Dollars: Industry-Wide Reform of Reimbursement System Will End Conflicts of Interest and Create Fair Rates for Consumers Nationwide
[New York Office of the Attorney General]
NEW YORK, NY (January 13, 2009) - Attorney General Andrew M. Cuomo today announced historic reform of the nationwide health care reimbursement system that will end conflicts of interest and generate fair reimbursement rates for working families nationwide. Cuomo has reached an agreement with UnitedHealth Group Inc. (NYSE: UNH) ("United"), the nation's second largest health insurer, after conducting an industry-wide investigation into a scheme to defraud consumers by manipulating reimbursement rates.
At the center of the scheme is Ingenix, Inc. ("Ingenix"), a wholly-owned subsidiary of United, which is the nation's largest provider of health care billing information. Under the agreement with United, the database of billing information operated by Ingenix will close. United will pay $50 million to a qualified nonprofit organization that will establish a new, independent database to help determine fair out-of-network reimbursement rates for consumers throughout the United States.
"For the past ten years, American patients have suffered from unfair reimbursements for critical medical services due to a conflict-ridden system that has been owned, operated, and manipulated by the health insurance industry. This agreement marks the end of that flawed system," said Attorney General Cuomo. "As working families throughout our nation struggle with the burden of health care costs, we will make sure that health insurers keep their promise to pay their fair share. The industry reforms that we announce today will bring crucial accuracy, transparency, and independence to a broken system. During these tough economic times, this agreement will keep hundreds of millions of dollars in the pockets of over one hundred million Americans."
In February 2008, the Attorney General announced an industry-wide investigation into allegations that health insurers unfairly saddle consumers with too much of the cost of out-of-network health care. Seventy percent of insured working Americans pay higher premiums for insurance plans that allow them to use out-of-network doctors. In exchange, insurers often promise to cover up to eighty percent of the "usual and customary" rate of the out-of-network expenses, and consumers are responsible for paying the balance of the bill.
United and the largest health insurers in the country rely on the United-owned Ingenix database to determine their "usual and customary" rates. The Ingenix database uses the insurers' billing information to calculate "usual and customary" rates for individual claims by assessing how much the same, or similar, medical services would typically cost, generally taking into account the type of service and geographical location. Under this system, insurers control reimbursement rates that are supposed to fairly reflect the market.
Attorney General Cuomo's investigation concerned allegations that the Ingenix database intentionally skewed "usual and customary" rates downward through faulty data collection, poor pooling procedures, and the lack of audits. That means many consumers were forced to pay more than they should have. The investigation found the rate of underpayment by insurers ranged from ten to twenty-eight percent for various medical services across the state. The Attorney General found that having a health insurer determine the "usual and customary" rate - a large portion of which the insurer then reimburses - creates an incentive for the insurer to manipulate the rate downward. The creation of a new database, independently maintained by a nonprofit organization, is designed to remove this conflict of interest.

[swimangel72]

Thanks for posting this Lani - perfect timing for me since I had to switch to an insurance plan that takes out-of-network doctors so my hernia repair this summer would be covered by a specialist. Hopefully these changes will mean less out-of-pocket expenses for me!

[freyja]

Hopefully this is a sign of even better changes to come!

[harrie]

Lani, that is so encouraging! I have had my share of problems with my insurance co in regards to unfair reimbursements.
One such example, there are many at out site that have had their DIEP reconstuction paid very well by their insurance company. Mine paid minimally leaving me with a very large out of pocket cost.
Same situation with my Oncotype DX and now with my annual DEXA.