Andrew Cuomo, UnitedHealthCare: Duh

Those of you who have the misfortune of having spent time with me know that I tell a lot of stories, often more than once. I also use the same punchlines a lot.
One little routine I’ve inserted into seminars, phone calls, and lunches a thousand times over the last decade is the UHC/Ingenix piece. “Sure, there is another place where you can get some of the data I’m talking about – Ingenix. You know who owns them, though, right?” Very few people have ever known before I told them.

I have always felt compelled to share my discomfort relating to the Ingenix data, before I even knew about the UHC connection. I remember buying that expensive CD program in order to look up pricing information. I opened it up and though, “Holy cow, to do this right, I need a lot more data and these people have it on a silver platter!” In fact, they were my inspiration for creating the RVUcalculators – I felt it a bit ridiculous that pediatricians should have to pay for RVU information.

Anyway, there are parts of the country where PCC has a concentration of customers or extra knowledge about a local market. Here in Vermont, for example. Or San Antonio, northern NJ, Tulsa, etc. Every time I checked the Ingenix software for the “usual and customary” prices…they just seemed lower than what I would have expected. Had they simply been different, some high and some low, I’d have understood. But it’s always low. If there are only six pediatric offices here in our county and I know the prices to all of them, and Ingenix reports a lower median price – how is that?

Here’s the other question: where does this data come from? How does UHC/Ingenix get CPT/pricing level data from places like Vermont, where they don’t actually have a presence? Doesn’t that seem odd? If the data isn’t for sale (gross!) then how are they getting it?
For that random person hitting this blog who doesn’t know what I’m talking about, you can hear NPR’s take on Andrew Cuomo’s investigation of UnitedHealthCare. Better, check out NY’s press release. My favorite quote from it:

Cuomo’s investigation also found a clear example of the scheme: United insurers knew most simple doctor visits cost $200, but claimed to their members the typical rate was only $77. The insurers then applied the contractual reimbursement rate of 80%, covering only $62 for a $200 bill, and leaving the patient to cover the $138 balance.

The real question: is anyone surprised?
Update: the NY Times has finally gotten into the commentary.  My bet? This goes nowhere important.

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  1. Pingback: Making Your Health Insurance Company Pay Up - Jeffrey Dach MD

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