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THE DEATH OF
MANAGED-CARE MODEL
& HEALTH INSURANCE
INDUSTRY UCR FRAUD
© JIN ZHOU, President,
ERISAclaim.com
March 27,
2009
The managed-care model for US healthcare industry
is dead after it has failed to contain
skyrocketing healthcare
costs and
medical inflation in the past decade as originally intended
and has resulted in more than
48 million Americans uninsured, in the
wake of litigation explosion by
healthcare providers and consumers against managed-care entities and
recent investigation conducted by the Attorney General of New
York which concluded that for a number of years, the insurance
industry has systematically under-estimated the out-of-network
reimbursement rates it pays its policy holders, costing consumers
billions of dollars in excessive out-of-pocket costs, with subsequent
settlements by many industry managed-care insurers and more
litigations for the rest, and the Congressional investigation now, on
March 26, 2009, the Senate Committee on Commerce, Science, and
Transportation announces a full committee hearing on Deceptive Health
Insurance Industry Practices – Are Consumers Getting What They Paid
For?.
The managed-care model gained its power and
market control decades ago by private managed-care contracting directly with
healthcare providers initially through HMO model's capitated fee
schedule to reduce unnecessary healthcare services, subsequently
through PPO model which penalizing out-of-network provider access
through UCR (usual, customary and reasonable) fee schedule
manipulation and in network PPO fee reduction through "voluntary"
contracting in exchange with wholesale referral of patients. With
initial short-term success from both HMO and PPO models, yet the market
continued to deteriorate with
uncontrolled skyrocketing healthcare
costs while managed-care contracting replaced, hijacked or otherwise
substituted or replaced almost all public policies, regulatory enforcement in
both federal laws, ERISA, and state
insurance laws, managed-care and consumer protection laws for medical
necessity review (utilization review) and network access by consumers.
With its continued failure to contain
health-care costs through gatekeeping medical necessity reviewers for HMO model, and medical
necessity review coupled with PPO contracting fee reduction and
non-PPO UCR reduction for PPO model, managed-care industry responded
to with initial POS ( Point of Service) and subsequent P4P
(Pay-For-Performance) in an attempt to save managed-care model.
Ultimately managed-care model has completely failed to contain
US healthcare costs with
skyrocketing medical inflation and
unprecedented 48 million uninsured Americans.
Now that non-PPO UCR fee schedule of managed care
model will soon be a public or regulatory matter,
as UnitedHealth said its statements:
“Once the new database is
operational, the Ingenix databases will be closed and not available to
any health insurer,” and
as Senator Rockefeller says his goal is "to ensure that the
practice of underpaying for out-of-network doctor visits
is ended in every state, not just New York".
Once managed care model's out-of-network
UCR fee schedules no longer hold
water in public, regulatory and legislative environment,
the all in-network PPO savings for entire managed care attractions
will disappear. Managed care model for U.S. healthcare is
now completely dead, with market
symptoms as 95,000 doctor's class action lawsuit, in critical
condition with
New York Attorney General's Investigation of and settlement with
UnitedHealthcare, and
obituary and funeral notice with Senate Hearing on March 26, 2009:
"Deceptive
Health Insurance Industry Practices – Are Consumers Getting What They
Paid For?" and
Mr. Stephen J. Hemsley's Testimony
as President and Chief Executive Officer UnitedHealth Group before
The Senate Committee on Commerce, Science, and Transportation.
Goodbye to Managed Care Model for
U.S. healthcare industry!
Managed-Care Model, through private contracting
for USA health industry for decades by complete disregard of
federal law, ERISA, which was truly intended by Congress to completely
govern and control healthcare costs and reimbursement dispute for more
than 90% of non-Medicare claims, and through escaping state laws
in managed-care and consumer protections, has been completely dead
from its heart and core for its power to contain or control
health-care costs and improve healthcare quality but still with very
enticing appearance for any blind crusader to resuscitate healthcare
industry.
One of the worst tragedy or mistake by USA for
healthcare industry and US economy,
similar to 9/11 disaster, is
the
"Failure of Imagination", as concluded by Congressional 9/11
Commission. 34 years ago in 1974, Congress has intended and
decided to enact a federal law, ERISA
(Employee Retirement Income Security Act of 1974), to completely and
100% regulate and control healthcare claim reimbursement and
dispute for 160 to 175 million working Americans covered
under employer-sponsored plans. As clearly as United States Supreme
Court interpreted (Aetna v. Davila) that ERISA completely
(100%) regulates and governs all of the money dispute as benefits
denials from employer-sponsored health plans and (100%)
completely preempts or validates any and all state laws and managed
care contracting when a dispute is "denial of benefits" with ERISA
plans. However entire USA has
completely failed to understand, or imagine, that Congress
intended to use public policy, ERISA
law, instead of managed-care private contracting, to contain
health-care costs and resolve health-care money disputes and access to
quality healthcare. A "Failure of
Imagination" again for U.S. healthcare and economy, in
addition to homeland security and antiterrorist, as explained and
concluded
by Congressional 9/11 Commission.
While New York State attorney general at the
state level and Senate committee at federal level are investigating
and concluding a systematic failure and fraud by
health-insurance industry policies,
On July 25, 2008, President Obama expressed his
frustrations in US DOL's failure to enforce US labor laws in general in
his presidential campaign last year, he now appointed a new law
professor extremely experienced in ERISA to head the USDOL's EBSA, a
division of DOL in charge of ERISA claim regulation, after
decades of DOL's total failure
in federal regulatory enforcement of ERISA Claim Regulation through a
symbolic enforcement with pure "Voluntary
Compliance
Assistance" for any and all violators with little or no
enforcement under the
Congressional Leaders' Non-Obama
Guidance. Although a
strong indication that Obama administration is heading the right
direction to avoid "Failure of
Imagination" again, to enforce ERISA claim regulation as
intended by Congress and interpreted by United States Supreme Court,
to truly save health care costs and reduce uninsured Americans,
whether Obama administration will succeed in this healthcare and
managed-care crisis turnaround remains to be seen.
For the rest of world on the U.S.
healthcare landscape at this critical juncture of U.S. economic
recession and healthcare critical condition in ICU when managed-care
model that we have married to for so long being dead and 34-year-old
statutory spouse of ERISA (may a girl's name) yet totally unknown to
us, we must educate ourselves and turn to ERISA to be the
first
one on the block or on the top of the this picture when the next
US
healthcare chapter is out of Chapter 11.
Dr. Jin Zhou, the president of
ERISAclaim.com, respectively
invite you to review the following breaking developments and statutory
facts, and draw your own conclusions based on the facts and laws.
ERISA
Completely (100%) Regulates, Governs and Controls Pricing and
Payment or Cost for Employer
Sponsored Health Plans for More than 90% of Non-Medicare Claims, and
ERISA Mandates UCR Fee Schedule Disclosures (DOL
ERISA FAQ B5)
Opinion of the U.S. Supreme Court
06/21/04
Aetna Health Inc. v. Davila
"Held: Respondents’ state causes of action
fall within ERISA§502(a)(1)(B), and are therefore completely
pre-empted by ERISA §502 and removable to federal court.
Pp. 4–20."
"We hold that respondents’ causes of action,
brought to remedy only the denial of
benefits under
ERISA-regulated benefit plans,
fall within the scope of, and are completely pre-empted by,
ERISA §502(a)(1)(B), and thus removable to federal
district court. The judgment of the Court of Appeals is
reversed, and the cases are remanded for further proceedings
consistent with this opinion.7
It is so ordered."
$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$
B-5: For purposes of furnishing relevant documents to a claimant, what
kind of disclosure is required to demonstrate compliance with the
administrative processes and safeguards required to ensure and verify
appropriately consistent decision making in making the benefit
determination?
What documents will be required to be disclosed will depend on the
particular processes and safeguards that a plan has established and
maintains to ensure and verify appropriately consistent decision
making. See 65 FR at 70252. The department does not anticipate new
documents being developed solely to comply with this disclosure
requirement. Rather, the department anticipates that claimants who
request this disclosure will be provided with what the plan actually
used, in the case of the specific claim denial, to satisfy this
requirement. The plan could, for example, provide the specific plan
rules or guidelines governing the application of specific protocols,
criteria,
rate tables, fee schedules, etc. to claims like the claim at
issue, or the specific checklist or cross-checking document that
served to affirm that the plan rules or guidelines were
appropriately applied to the claimant’s claim. Plans are not
required to disclose other claimants’ individual records or
information specific to the resolution of other claims in order to
comply with this requirement. See § 2560.503-1(m)(8)(iii). See
question D-12."
<http://www.dol.gov/ebsa/faqs/faq_claims_proc_reg.html>
==========================================
Excerpt: "President Obama on Tuesday during a prime-time news
conference linked issues within the U.S. budget in part to high
health care costs, stating that 'almost every single person' who
has examined the nation's budget has concluded that the government
must find a way to reduce health care costs, the Washington Post
reports (Shear/Wilson, Washington Post, 3/25)."
Fixing healthcare without addressing ERISA, the law 100%
governing more than 90% of non-Medicare claims in USA, is Impossible
- Jin Zhou
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The White House News: New ERISA Chief for USA:
"Phyllis C. Borzi, Nominee for Assistant Secretary of Labor
for Employee Benefits Security, Department of Labor"
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The White House News: New ERISA Chief for USA:
"Phyllis C. Borzi, Nominee for Assistant Secretary of Labor
for Employee Benefits Security, Department of Labor"
Excerpt: "Until January 1995, [Phyllis] Borzi served as pension and employee
benefit counsel for the U.S. House of Representatives, Subcommittee on
Labor-Management Relations of the Committee on Education and Labor. She was
on the Committee staff for 16 years. . . . . Borzi has published numerous
articles on ERISA, health care law and policy and retirement security issues
and is a frequent speaker on programs sponsored by legal, professional,
business, consumer and state and local governmental organizations. An active
member of the American Bar Association, Borzi is the current chair of the
ABA's Joint Committee on Employee Benefits . . . ."
Excerpt: "President Obama on Tuesday during a
prime-time news conference linked issues within the U.S. budget in
part to high health care costs, stating that 'almost every single
person' who has examined the nation's budget has concluded that the
government must find a way to reduce health care costs, the Washington
Post reports (Shear/Wilson, Washington Post, 3/25)."
Comments from Jin Zhou:
Fixing healthcare without addressing ERISA,
the law 100% governing more than 90% of non-Medicare claims in USA, is
Impossible - Jin Zhou
ERISA laws will be definitely enforced by this new ERISA Chief.....
ERISA appeals and practice will mean more than ever before....
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Thursday, 10:30 AM, March
26, 2009, The Senate Committee on Commerce, Science, and
Transportation announces a full committee hearing on Deceptive Health
Insurance Industry Practices – Are Consumers Getting What They Paid
For?
 
For Immediate Release
03/26/09
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Contact:
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Jena Longo -
Democratic Deputy Communications Director 202.224.7824
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Chairman Rockefeller Holds First Oversight and
Investigations Hearing on Deceptive Health Insurance
Industry Policies |
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WASHINGTON, D.C. – The Senate
Committee on Commerce, Science, and Transportation held a
full committee hearing today on “Deceptive Health Insurance
Industry Practices– Are Consumers Getting What They Paid
For?”
Today was the first of two
hearings examining how the health insurance industry
reimburses consumers for health care services. These
hearings focus on the way the industry calculates “usual,
customary and reasonable” reimbursement rates for consumers
who choose to receive care from out-of-network doctors and
other health care providers.
A recent investigation
conducted by the Attorney General of New York concluded that
for a number of years, the insurance industry has
systematically under-estimated the out-of-network
reimbursement rates it pays its policy holders, costing
consumers billions of dollars in excessive out-of-pocket
costs. The victims of this deceptive practice – more than
100 million Americans who pay for health insurance coverage
that allows them to go outside of their provider network for
medical care.
Key Quotes From
Today’s Hearing:
• “The health insurance
industry has been promising to pay a certain share of
consumers’ medical bills, but then they have been rigging
health charge data to avoid paying their fair share,”
Rockefeller said. “The result is that billions of dollars
in health care costs have been unfairly shifted to millions
of American consumers.”
• In written testimony, Dr.
Mary Jerome, a cancer patient, shared her personal
experience with unfair practices and fees: “When I was
diagnosed with cancer, I thought the most difficult hurdle I
would face would be the disease. Little did I know, that
dealing with my insurance company would be my greater
battle, because unknown to me, they were operating with
deceptive methods of reimbursement. I had to battle cancer –
and I am still battling it – and I had to battle my
insurance company to try and get fair coverage. It was
almost too much to bear.
• “Nationwide,
medical costs are the leading cause of individual
bankruptcy, even though the individual usually had
insurance,” testified Linda Lacewell, representing the
Office of the New York State Attorney General. “Fraudulent
under-reimbursement for insured Americans is one part of
this negative equation for consumers.”
• Representing the Consumers
Union, Chuck Bell explained: “The key problem with the
out-of-network reimbursement system is that the UCR (“usual,
customary and reasonable”) rates were not calculated in a
fair and impartial way. For the last ten years or so, the
primary databases that are used by insurers to determine
“usual, customary and reasonable” rates have been owned by
Ingenix, a wholly-owned subsidiary of UnitedHealth Group.”
• Dr. Nancy Nielsen, president
of the AMA, was joined by the Medical Society of the State
of New York, the Missouri State Medical Association and
several other parties in initiating a class-action lawsuit
against United Health Group for using skewed data to
determine out-of-network payment rates.
“After nearly a
decade of litigation, the AMA is very pleased that United
Health Group recognized the importance of restoring its
relationship with patients and physicians and is settling
the AMA’s lawsuit by agreeing to pay $350 million toward
reimbursing the patients and physicians it short-changed,
and by confirming in federal court its separate agreement
with New York Attorney General Cuomo to end the use of this
database and trust its repair and operation to a
not-for-profit institution,” Dr. Nielsen testified.
***On Tuesday, March
31, 2009 at 10:00 a.m., the full committee will conduct the
second part of this hearing on deceptive health industry
practices with testimony from Mr. Stephen J. Hemsley,
President and Chief Executive Officer of UnitedHealth Group
and Mr. Andy Slavitt, Chief Executive Officer of Ingenix.***
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PART I: Deceptive Health Insurance Industry
Practices – Are Consumers Getting What They Paid For?
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Thursday, March 26, 2009 |
10:30 AM
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SR - 253 |
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View Archive Webcast |
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Washington,
DC-- The Senate Committee on Commerce, Science, and
Transportation announces a full committee hearing on
Deceptive Health Insurance Industry Practices – Are
Consumers Getting What They Paid For? The Committee will be
holding two hearings examining how the health insurance
industry reimburses consumers for health care services.
These hearings will focus on the way the industry calculates
“usual and customary” reimbursement rates for consumers who
choose to receive care from out-of-network doctors and other
health care providers.
A recent
investigation conducted by the Attorney General of New York
concluded that for a number of years, the insurance industry
has systematically under-estimated the out-of-network
reimbursement rates it pays its policy holders, costing
consumers billions of dollars in excessive out-of-pocket
costs. The Committee will take testimony about this
investigation and about its implications for consumers
nationwide.
Majority Statements
John D. Rockefeller, IV
Witnesses
Opening Remarks
Panel 1
Chuck Bell
Programs Director
Consumers Union
Dr. Mary Jerome
Yonkers
New York
Linda A. Lacewell
Counsel for Economic and Social Justice and Head of the
Healthcare Industry Taskforce
Office of the New York State Attorney General
Dr. Nancy H. Nielsen
President
American Medical Association
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Statement of
John D. Rockefeller, IV
Hearing: PART I: Deceptive Health Insurance Industry Practices –
Are Consumers Getting What They Paid For?
Thursday, March 26, 2009
Opening
Statement – John D. (Jay) Rockefeller IV, Chairman
Good Morning. Today’s hearing is the first of two hearings we
are holding to look at a
deceptive payment practice that the health insurance industry
has gotten away with for the last decade, maybe even longer.
The victims of this
deceptive practice were probably most of the people sitting in
this hearing room today, along with the more than 100 million
Americans who pay for health insurance coverage that allows them
to go outside of their provider network for medical care.
Having the ability to get health care services outside of their
network is an important option for American consumers, and it’s
an option they pay for – in the form of higher premiums, higher
deductibles, and higher co-insurance payments.
We were scheduled to hear today from Dr. Mary Jerome, a resident
of Yonkers, New York, who has been fighting ovarian cancer since
2006.
Dr. Jerome was not feeling well enough to coming down to
Washington today to testify, but she was kind enough to send us
her testimony. I ask unanimous consent to make her testimony
part of the hearing record.
According to her testimony, Dr. Jerome received her health care
coverage through a Point of Service plan, which encouraged her
to get care within a provider network, but also allowed her to
see out-of-network providers if necessary.
Here’s what she says in her testimony: “I had always been
confident that paying for the out-of-network option provided
peace of mind with respect to the financial burdens associated
with catastrophic medical costs.”
After her cancer diagnosis, Dr. Jerome and her in-network
primary care physician decided she needed to be treated by a
health care provider that was outside of her network, the
Memorial Sloan Kettering Cancer Center in New York City.
Dr. Jerome knew she was going to have to pay some portion of
these costs out of her own pocket, but she also assumed in good
faith that the treatment was going to be covered by her
insurance.
What we are going to learn today is that American consumers like
Dr. Jerome – people who have been paying higher premiums for the
choice to see out-of-network doctors - have not been getting
what they paid for.
We are going to hear testimony suggesting that the health
insurance industry has been systematically lowballing American
consumers.
They have been promising to pay a certain share of consumers’
medical bills, but then they have been rigging health charge
data to avoid paying their fair share.
The result is that billions of dollars in health care costs have
been unfairly shifted to Dr. Jerome and millions of other
American consumers like her.
Here’s how it works: the insurance companies generally promise
to reimburse out-of-network medical services at what they refer
to in the industry as the “usual, customary, and reasonable”
rate.
Well, the problem is that it’s been the insurance industry who’s
been deciding what “usual, customary, and reasonable” means.
Consumers haven’t had any input, doctors and other health care
providers haven’t had any input. Only the insurance companies
have been getting to decide what’s reasonable.
That’s like letting the fox define “usual, customary and
reasonable” in the henhouse.
The good news is that
thanks to a series of lawsuits and a year-long investigation by
the New York Attorney General’s office, the insurance companies
that operate in New York – including, most importantly,
UnitedHealth Group and its medical information subsidiary,
Ingenix - have been forced to change the way they do business.
Our goal for today is to get an update on how the reforms
proposed in New York are being implemented, and to understand
how the deceptive practices uncovered in New York have been
harming consumers in the other 49 states.
I am looking forward to this testimony, especially at a time
when we are once again taking a good, hard look at our country’s
health care system.
I would like to finally note that missing from our hearing today
is one group of stakeholders who played an indispensable role in
creating and perpetuating this unfair reimbursement system, but
who will also play an essential role in changing it – the
insurance industry.
On March 9, 2009, I invited the CEOs of UnitedHealth Group and
Ingenix to testify at this hearing today so we could hear their
side of the story. Because UnitedHealth told us that their CEO,
Mr. Stephen Hemsley, was not available to testify today, we
agreed to hold a second hearing next week.
At 10 AM next Tuesday, March 31, 2009, we will be holding a
hearing during which we hope to gain a better understanding of
the insurers’ perspective.
I now yield to the Ranking Member for her opening statement.
###
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01/13/2009
Attorney General Cuomo Announces
Historic Nationwide Health Insurance Reform; Ends Practice Of Manipulating
Rates To Overcharge Patients By Hundreds Of Millions Of Dollars
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Breaking News
in 2009 for Healthcare Reimbursement
© JIN ZHOU, President,
ERISAclaim.com
Jan. 13, 2009
on January 13, 2009,
Attorney General Cuomo
Announces Historic Nationwide Health Insurance Reform; Ends Practice Of
Manipulating Rates To Overcharge Patients By Hundreds Of Millions Of Dollars.
The industry wide UCR scam is the biggest consumer fraud of the Century with
conflict of interest
on January 8, 2009,
California Supreme Court ruled that
healthcare provide must appeal claim denials on UCR to HMO, health plans,
under ERISA for ERISA regulated employer-sponsored plans. health-care
providers may not balance bill HMO patient. HMOs may not simply reimburse
healthcare providers at the Medicare rate.
More than 80% of non-Medicare claims
in USA are ERISA claims, and "Seventy percent of insured working Americans
pay higher premiums for insurance plans that allow them to use
out-of-network doctors."
In the worst economic crisis for 2009,
healthcare providers must learn and do ERISA and Medicare claim appeals, or
be out of business.
NY AG's Settlement Press Release and California Supreme
Court Ruling are captioned below with color-coded notation.
If you have any questions, please contact Dr. Jin Zhou,
the president of the ERISAclaim.com at
ERISAclaim@aol.com.
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01/13/2009
Attorney General Cuomo Announces
Historic Nationwide Health Insurance Reform; Ends Practice Of Manipulating
Rates To Overcharge Patients By Hundreds Of Millions Of Dollars
Industry-Wide Reform of
Reimbursement System Will End Conflicts of Interest and Create Fair
Rates for Consumers Nationwide
NEW YORK, NY
(January 13, 2009) – Attorney General Andrew M. Cuomo today
announced historic reform of the nationwide health care
reimbursement system that will end conflicts of interest and
generate fair reimbursement rates for working families nationwide.
Cuomo has reached an agreement with UnitedHealth Group Inc. (NYSE:
UNH) (“United”), the nation’s second largest health insurer, after
conducting an industry-wide investigation into
a scheme to defraud consumers by manipulating reimbursement rates.
At the center of the
scheme is Ingenix, Inc. (“Ingenix”), a
wholly-owned subsidiary of United, which is the nation’s largest
provider of health care billing information. Under the agreement
with United, the database of billing information operated by Ingenix
will close. United will pay $50 million
to a qualified nonprofit organization that will establish a new,
independent database to help determine fair out-of-network
reimbursement rates for consumers throughout the United States.
“For
the past ten years, American patients have suffered from
unfair reimbursements for critical medical
services due to a conflict-ridden system that has been owned,
operated, and manipulated by the health insurance industry.
This agreement marks the end of that flawed system,” said Attorney
General Cuomo. “As working families throughout our nation struggle
with the burden of health care costs, we will make sure that health
insurers keep their promise to pay their fair share. The industry
reforms that we announce today will bring crucial accuracy,
transparency, and independence to a broken system.
During these tough economic times, this
agreement will keep hundreds of millions of dollars in the pockets
of over one hundred million Americans.”
In February 2008,
the Attorney General announced an industry-wide investigation into
allegations that health insurers unfairly saddle consumers with too
much of the cost of out-of-network health care.
Seventy percent of insured working Americans pay higher premiums
for insurance plans that allow them to use
out-of-network doctors. In
exchange, insurers often promise to cover up to eighty percent
of the “usual and customary” rate of the
out-of-network expenses, and consumers are responsible for
paying the balance of the bill.
United and the
largest health insurers in the country rely on the United-owned
Ingenix database to determine their “usual and
customary” rates. 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.
Attorney General
Cuomo’s investigation concerned allegations that 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 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. The creation of a new database, independently
maintained by a nonprofit organization, is designed to remove this
conflict of interest.
Under Attorney General Cuomo’s
agreement with United:
 | United will pay
$50 million to establish a new,
independent database run by a qualified nonprofit organization;
|
| The
nonprofit will own and operate the new database, and will
be the sole arbiter and decision-maker with respect to all data
contribution protocols and all other methodologies used in
connection with the database; |
| The
nonprofit will develop a website where, for the first time,
consumers around the country can find out in
advance how much they may be reimbursed for common out-of-network
medical services in their area; |
| The nonprofit will make rate
information from the database available to
health insurers; |
| The
nonprofit will use the new database to conduct academic
research to help improve the health care system;
|
| The nonprofit will be selected
and announced at a future date. |
In February 2008,
Cuomo also announced that he had issued subpoenas to the nation’s
largest health insurance companies that use the Ingenix database,
including Aetna (NYSE: AET), CIGNA (NYSE: CI),
and WellPoint/Empire BlueCross BlueShield (NYSE: WLP). The Attorney
General’s industry-wide investigation is ongoing.
Cuomo continued,
“Our agreement with United removes the
conflicts of interest that have been inherent in the consumer
reimbursement system. This has been an industry-wide problem, and
it demands an industry-wide reform. We commend United for leading
the industry on this issue, and we encourage
other insurers to follow suit.”
Cuomo was joined by
representatives from United and from leading medical and consumer
organizations in making today’s announcement at the Saint Vincent
Catholic Medical Center in Manhattan.
“We are committed to
increasing the amount of useful information available in the health
care marketplace so that people can make informed decisions, and
this agreement is consistent with that approach and philosophy,”
said Thomas L. Strickland, Executive Vice President and Chief Legal
Officer of UnitedHealth Group. “We are pleased that a
not-for-profit entity will play this important role for the
marketplace.”
President of the American Medical Association
(AMA), Nancy Nielsen, M.D., said, “Today, patients and
physicians prevailed over health insurance giant UnitedHealth Group
when New York Attorney General Cuomo stopped the insurer from using
a rigged Ingenix database that increased insurer profits at the
expense of patients and physicians. The AMA appreciates the
leadership of Attorney General Cuomo in initiating his investigation
into the Ingenix database, and fully supports the Attorney General’s
actions to have a nonprofit entity create a new, reliable database
that is fair to patients and physicians.”
President of the
Medical Society of the State of New York (MSSNY) Michael H.
Rosenberg, M.D., said, “We thank Attorney General Cuomo for taking
decisive action to finally achieve one of the major goals of a
lawsuit that the Medical Society of the State of New York initiated
with two other medical societies over eight years ago. Because of
the thorough research and diligent negotiation of Mr. Cuomo and his
expert staff, patients and their physicians will no longer be
subject to inadequate out-of-network payments determined by the
flawed Ingenix database.”
Consumers Union
Programs Director Chuck Bell said, “Consumers
Union greatly appreciates the care that Attorney General
Cuomo and his staff have taken in investigating these issues, and
creating the careful architecture in this settlement. This is an
extremely sensible, fair solution, which will be of great benefit
for consumers nationwide. We appreciate the fact that United
Healthcare has come to the table to resolve these issues in a
comprehensive way, and we hope that other insurance companies will
quickly get on board, and strongly support this excellent plan to
improve transparency for out-of-network charges.” Consumers Union
is the nonprofit publisher of Consumer Reports.
Today, Cuomo also
issued a report on his investigation, “Health Care Report: The
Consumer Reimbursement System is Code Blue.” The report highlights
the conflicts of interest and other defects in the current system
and calls for the reforms announced today. It can be accessed at
http://www.oag.state.ny.us/bureaus/health_care/HIT/reimbursement_rates.html.
The agreement
announced today is the result of an investigation by Deputy Chief of
the Health Care Bureau James E. Dering, Senior Trial Counsel Kathryn
E. Diaz, and Assistant Attorneys General Brant Campbell and Sandra
Rodriguez, under the direction of Linda A. Lacewell, the head of the
Attorney General’s Healthcare Industry Taskforce. The Attorney
General expressed his appreciation to Steven E. Fineman, Esq., of
Lieff Cabraser Heimann & Bernstein, LLP, for his pro bono
services in this matter.
For more
information, including consumer tips for out-of-network care, or to
file a complaint, please visit
http://www.oag.state.ny.us/bureaus/health_care/HIT/reimbursement_rates.html."
**************************
2009 UCR in the Media
Health
insurer accused of overcharging millions - Health - TODAYshow.com
“This is a huge scam
that affected hundreds of millions of Americans [who were] ripped off by
their health insurance companies,” says Cuomo. “This was unethical, and it
robbed vulnerable patients of insurance reimbursements they deserved.”
“This is huge.
This problem went across the country,” Nancy Nielsen,
president of the American Medical Association, told the TODAY show. “It’s
industry-wide, throughout insurers. So, it touched every state. Many
doctors, many millions of patients, and this has been going on for years.”
$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$
Unions Obtain Historic Health Care
Settlement for Members and ...
MSNBC - 8 hours ago
On Tuesday, New York Attorney General Andrew Cuomo
announced a settlement with United Healthcare in which a new and independent
database would be ...
Pomerantz
Announces $350 Million Settlement With United
Healthcare ...
MSNBC
© JIN ZHOU, President,
ERISAclaim.com
Jan. 16, 2009
|
Markets News | Reuters
|
* Doctors group says
transparency means savings
* AMA urges more openness on out-of-network
services
"WASHINGTON, March 26 (Reuters) -
Requiring health insurers
to be more open about how they set reimbursement rates for
out-of-network medical services would save
everyone money, the top U.S. doctors group told
Congress on Thursday.
American Medical Association President Nancy
Nielsen said such a move would prevent insurance companies from
shortchanging patients and upsetting their relationship with their
doctors by underestimating what doctors should be charging for
services.
"The
AMA believes enormous savings would accrue to patients,
physicians, health insurers and other third-party payers if there
were complete transparency," she told the Senate Commerce, Science
and Transportation Committee."
|
For more information on how to file
appeals for any specific type of denials, please visit DOL website or
ERISAclaim.com, you may also contact Dr. Jin Zhou at ERISAclaim.com
through ERISAclaim@aol.com.
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ERISA &
Claim Denials
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Aetna Video Shows ERISA Patients Mistreated
"According to the video, when faced with claims for identical
medical problems, Aetna separates the claims where no damages
are available - those subject to the federal Employee Retirement
Income Security Act, or ERISA - from non-ERISA claims, where
consumers can sue.1 2" |
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ERISA &
Health Claim |
|
What Is
ERISA and How Does It Affect Patient Rights?
"ERISA was enacted in 1974 to protect the pension and welfare
benefits that employers provide their workers. It currently
covers about 2.5 million health plans and 125 million workers,
retirees, and dependents." |
|
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$10,600 ERISA Claim
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| Recent Federal Court Ruling in a Case with
$10,600 medical claim, insurance Co. refused to pay, provider
made numerous demand for payment in almost one year, but no
appeals filed, the court dismissed the lawsuit because provider
failed to exhaust administrative remedy, as required under ERISA,
by filing ERISAclaim appeals. This situation is so popular
in health-care community.
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