Kudos to Andrew Cuomo for finally busting Ingenix and their “usual and customary” database. Ingenix is part of our good friends UnitedHealth Group-easily the most detested payor in the PT world.
The problem is that Ingenix is also hired by most states to help set their work comp rates. They “sell” their independence from UnitedHealth Group in setting these rates but who cares-we now know their database integrity is to say the least lacking.
By way of background, the case started in 2006 when a patient was left with huge bills for ovarian cancer despite supposedly having full insurance. Apparently, in the Ingenix routinely publishes phony numbers that look like they will reimburse X when the reality is that it is reimbursed Y.
For example, let’s say an out of network patient comes in for a PT eval. Their database might say that “usual and customary” is reimbursed $100 for PT eval (ok, bad example but you get the point). However, the payor reimburses $70 and leaves the patient with a $30 bill. You can imagine the frustration a consumer has when they assume that it is being reimbursed at one rate and it ends up quite another. In the case of something like cancer, it can be huge dollar differences.
The settlement of $50 million isn’t much for a company who gave their CEO more than 10x that in options, however, the other part of the settlement is for an independent non-profit to develop and manage a real database. Real transparency might be around the corner-not sure if this will bode well for practitioners or not but at least patients will have a better clue as to what they are paying.
