Legal Settlements Could Help Patients Recoup Money For Overpayments On Out-Of-Network Care

Main Category: Health Insurance / Medical Insurance
Also Included In: Litigation / Medical Malpractice
Article Date: 06 Feb 2009 - 2:00 PDT

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A "string of recent legal settlements with big health insurers may allow" members of managed-care plans to "begin recovering some of the money they may have overpaid" for using out-of-network medical services, the Wall Street Journal reports. Health insurers reimburse out-of-network care at what is termed the "usual-and-customary rate," which is often lower than the actual fee a provider charges. Patients sometimes can be forced to pay even more because reimbursements for out-of-network care are frequently calculated as a percentage of the usual fee, not the actual fee charged by the provider. When payments are less than what physicians charge for a procedure, patients can be charged the difference or physicians can go without full reimbursement.

Investigations by New York state Attorney General Andrew Cuomo (D) reported that the Ingenix database -- a system owned by UnitedHealth that is used by many insurers to calculate reasonable and customary rates of reimbursement -- has calculated rates between 10% and 28% too low. As a result, many people overpaid for out-of-network care. UnitedHealth, Aetna, HealthNet and MVP Healthcare have all settled investigations by Cuomo's office by agreeing to pay millions of dollars to patients and physicians affected by underpayments and stop using Ingenix. The settlements also involve payments toward the development of a new, independent database to replace Ingenix.

Cuomo expects to reach similar deals with other insurers. "A number of other legal actions are pending that seek redress for patients and health care providers who claim they were underpaid by insurers for out-of-network services," according to the Journal. The Journal reports that consumer advocates and plaintiff attorneys believe patients should appeal any out-of-network reimbursements that they believe are too low, in order to keep the appeals process alive, which could help "patients stand a better chance of receiving a larger reimbursement once the new database is set up or sooner" (McQueen, Wall Street Journal, 2/5).

Reprinted with kind permission from http://www.kaisernetwork.org. You can view the entire Kaiser Daily Health Policy Report, search the archives, or sign up for email delivery at http://www.kaisernetwork.org/dailyreports/healthpolicy. The Kaiser Daily Health Policy Report is published for kaisernetwork.org, a free service of The Henry J. Kaiser Family Foundation.

© 2009 Advisory Board Company and Kaiser Family Foundation. All rights reserved.

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