Those of us lucky to still have medical insurance all know what happens if we see a doctor not on the company’s approved list. Referred to as “out of network” providers, most plans pay a smaller percentage of the bill when you use one of these doctors. Maybe your plan will pay 90% of the bill if you see a network provider, but only 80% if you don’t. There are lots of reasons people go to “out of network” providers. Preference for a particular doctor is one. Another is the sometimes long wait you must endure in order to get an appointment with the “network provider”. Some of these “network providers” limit the number of people they see under your plan. Others limit when they’ll see plan members to certain hours of the day, usually during slow times so you don’t get in the way of more lucrative patients. At least when you decide to go to the “out of network” provider you know up front you have to pick up the extra percentage your insurance won’t pay. But you actually pay more than just the extra percentage. Sometimes a lot more. That’s because most plans that state they’ll pay 80% of the “out of network” provider bill, discount the bill even further. They claim the bill from your doctor was excessive and as such, was above the “usual and customary” charge for that type of service in the community. Of course, the “out of network” provider you went to doesn’t agree. And he doesn’t have any agreement with your insurance company to accept what they pay. So you find yourself being billed for the difference. That 80% of the bill now looks more like 60% or 50% of the charge. And good luck trying to get the doctor to work it out with your insurance company. His staff will probably tell you they don’t have time to argue with insurance companies. And your doctor will say his rates are in line with everybody else around town. Well, it turns out he’s probably right. A recent AP article reported that insurance companies have been using a corrupt database to make you foot more of the bill. One of the nation’s largest, UnitedHealth Group Inc., just agreed to quit using a much criticized database as part of a deal to settle a fraud investigation brought by the New York attorney general’s office. They also agreed to spend $50 million to create a new database. One that will help millions of consumers pay less for "out-of-network" care. The new database will be operated by a nonprofit organization. It will replace two corrupt ones run by UnitedHealth Care’s Ingenix Inc., a subsidiary they used to determine just what "usual and customary" meant when consumers saw an “out of network” provider. The fraud investigation found that insurers using the Ingenix database commonly underpaid doctors as much as 28% less than the actual “usual and customary” rate. Consumers had to eat the difference. Attorney General Andrew Cuomo of New York said Tuesday during a press conference that the databases were riddled with conflicts of interest. He noted many health insurance companies across the nation still use Ingenix databases to set “usual and customary” rates. "I’m putting all the other health insurance companies on notice today," he said. "I believe all the companies that have been involved with Ingenix, there’s a very strong case that they were perpetrating consumer fraud, and we are going to aggressively pursue those cases." UnitedHealth could face troubles in other states too. The Connecticut attorney general’s office said Tuesday it was continuing an investigation into Ingenix.
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