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Cigna, Wellpoint Settle with Cuomo Over Reimbursements

Feb 18, 2009 | Parker Waichman LLP

Wellpoint and Cigna, two of the country's largest insurers, have as agreed to stop using the much-maligned Ingenix database for determining reimbursements for customers who seek out-of-network care.  Wellpoint and Cigna are just the latest insurers to reach an agreement with New York Attorney General over Ingenix.

The Ingenix database, owned by UnitedHealth Group, is used by many insurers to  determine their “usual and customary” rates for out-of-network care.  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.  

The investigation found that because of Ingenix, many consumers were forced to pay more than they should have for out-of-network care, with underpayment by insurers ranging 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  for a service – 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 Ingenix owner 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.

In addition to ending their use of the Ingenix database, WellPoint will pay $10 million toward the new database.  Cigna has pledged the same amount.

The Cigna and Wellpoint agreements are just the latest announced by Cuomo's office.  Aetna also recently agreed to end its relationship with Ingenix and contribute $20 million to the new database.  Cuomo reached smaller settlements with the Schenectady-based MVP Health Care, Inc./ Preferred Care, Buffalo-based Independent Health, and Buffalo-based HealthNow.  Insurers have so far pledged a total of $90 million to the new database company.

According to a statement  from Cuomo's office announcing the Wellpoint settlement, the Attorney General has also as filed notice of intent to sue two other Upstate insurers: Capital District Physician’s Health Plan  and Excellus Health Plan  (including its Buffalo-based affiliate, Univera), for continuing to defraud consumers and manipulate rates.

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