Cigna and Aetna  are the latest insurers to be hit with a lawsuit over the Ingenix database, which is used by many large health insurers to determine reimbursement rates.  The lawsuits, filed by the American Medical Association (AMA) and several state associations, claims that the Ingenix database was rigged to underpay doctors on out-of-network claims for more than a decade.

Ingenix is a subsidiary of UnitedHealth Group.  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.

Last year, the New York Attorney General’s office began an investigation into allegations 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’s investigation also  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.

In January, the New York Attorney General announced that it had reached a deal with UnitedHealth in which the company would pay $50 million to set up a new database for determining reimbursement.  The database is to be owned and operated by a non-profit organization in order to eliminate insurance company conflicts of interest.

A few days after the New York UnitedHealth settlement was announced, the insurer reach a $400 million settlement in a class action lawsuit filed by the AMA.  As part of the settlement, UnitedHealth agreed to put $350 million into a class-action restitution fund to pay physicians and policyholders for services provided by out-of-network providers.

Now the AMA is looking for the same type of relief from Cigna and Aetna.  According to The Wall Street Journal, the lawsuits accuse Aetna of deleting valid high charges from figures contributed to Ingenix’s database. They also accuse Cigna of hiding “serious, systemic flaws” in the data.

The medical associations of several states including Connecticut, New Jersey and New York, are named as plaintiffs in the lawsuits, as well as individual doctors. They seek relief for physicians who may have been harmed by the payment system, but no damage amounts are listed, the Journal said.

This entry was posted on Wednesday, February 11th, 2009 at 11:54 am and is filed under Consumer Fraud, Insurance Fraud, Legal News.