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UnitedHealthGroup Cheated Customers, NY Attorney General Claims

Feb 14, 2008 | Parker Waichman Alonso LLP

New York State Attorney General Andrew Cuomo said yesterday he is suing UnitedHealthGroup—the nation’s largest health insurer and its subsidiary Ingenix.  The New York attorney general also launched an industry-wide investigation into health care reimbursements.  Cuomo alleges that UnitedHealthGroup  manipulated data to cheat consumers, and he believes some insurance companies have been underpaying customers for a decade,  An investigation revealed two UnitedHealthGroup subsidiaries—United HealthCare Insurance Co. of New York Inc. and United Healthcare of New York Inc.—manipulated data to severely under-reimburse customers, to the tune of millions.  Cuomo has not yet filed charges, but said investigators found UnitedHealthGroup and its subsidiaries lied about data and manipulated numbers.

Cuomo said he would file a civil lawsuit to include three other subsidiaries of UnitedHealthGroup.  He  has subpoenaed 16 insurers, including Aetna, CIGNA, and Empire BlueCross BlueShield requesting they provide documents on how they computed reimbursements; copies of member complaints and appeals; and communications between members, Ingenix, and insurers. 

Cuomo's office said they found Ingenix’s reimbursement database—owned by UnitedHealthGroup and used by most major insurers—used data resulting in smaller payouts.

Linda Lacewell, head of Cuomo's health care industry taskforce, said, "United has a track record that stretches from Monterey to Montauk."  The potentially affected insured were those with "out-of-network" insurance allowing them treatment from doctors of their choice.  About 28,000 Long Islanders have such policies with United, a Cuomo spokesman said.  "When insurers like United receive convoluted and dishonest systems for determining the rate or reimbursement, real people get stuck with excessive bills and are less likely to seek the care they need," Cuomo said.

United said it is talking with Cuomo, "The reference data is rigorously developed, geographically specific, comprehensive, and organized using a transparent methodology that is very common in the healthcare industry."

Empire president Mark Wagar said they would continue to work with Cuomo to determine whether information used was inaccurate, "If that is found to be the case, Empire would consider any and all remedies available to protect the interests of our members, their families, our group customers, and providers in the New York marketplace and to maintain our company's historic commitment to fair and reasonable coverage."

Reimbursement is based on "reasonable and customary" geographic pricing; however, Cuomo said that while the United companies that used the database knew customary charges for a doctor's visit might average $200, reimbursement was based on a $77 rate; therefore, customers receiving 80 percent reimbursements would get about $61. 

"Based on the findings in this investigation," Consumers Union program director Chuck Bell said, "it appears that United Health failed to fulfill the promises it made to cover a fair portion of medical expenses and consumers were stuck with the bill."

Dr. Nancy Nielsen, president-elect of the American Medical Association said, "The investigation launched today by New York Attorney General Andrew Cuomo calls into question the validity of a system that health insurers have used for years to reimburse physicians and their enrolled members."

Dr. Robert Goldberg, president of the Medical Society of the State of New York, supported Cuomo’s investigation, saying there will be "long-term benefits to health care in New York" as a result of cracking down on reimbursement pricing.