More UCR News

  • United Healthcare and its Ingenix subsidiary raised the white flag again today by agreeing to settle the American Medical Association’s lawsuit over the validity of the Ingenix usual reasonable and customary (UCR) databases that insurers often use to set out-of-network provider rates. While not conceding liability, the defendants agreed to pay $350 million into a fund to be distributed to doctors and consumers. The lawsuit had been pending since 2000 in the federal district court in Manhattan. The AMA claims victory here.
  • The New York attorney general announced today that Aetna has agreed to contribute $20 million toward the cost of retaining a qualified university to create an independent UCR database. According to Aetna’s press release, Aetna

    will stop using the Ingenix databases for the purpose of determining “prevailing” or “usual, customary and reasonable” charges when members receive covered care from providers outside a health plan’s network. Aetna will instead help the Attorney General to create a new independent database for this purpose, and will use the new database when it is ready for use. Aetna is contributing $20 million to a nonprofit organization to help create the new database and to help educate members about reimbursement rates.

  • The New York AG’s press release provided more details:
  • Under Attorney General Cuomo’s agreement with Aetna:
  • Aetna will pay $20 million toward 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.
  • The AMA in another press release called upon insurers to follow Aetna’s lead. However, the Ingenix databases are not the only show in town. Many insurers use Medicare’s resource based relative value schedule (RVRBS) to set their out of network rates.