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Health Net Agrees to Stop Using Ingenix Database for Calculating Reasonable and Customary Fees

Posted Jun 18 2009 10:44pm

Also Ingenix is moving promptly to market additional business intelligence software to hospitals with the announcement of the Ingenix Revenue Manager.   It will connect with Ingenix Consulting services to identify causes for claims denials, prevent denials from happening, it states. image

“Ingenix Revenue Manager is comprised of three modules – Denials Prevention, Appeals Automation, and Denials Analytics – that can be applied separately or as a suite to automate, update and monitor billing processes, reduce the number of days claims are delayed in accounts receivable, prevent denials and minimize collections costs.”

After all that has been in the news, do you trust them with clean algorithms that won’t lead to something like this happening again with consumers getting billed for more services?  It is all about business intelligence software making 95% of the decisions today.  Ingenix made over a billion in profits last year too with most all the other major carriers using “their” data base for computations, maybe a small gold mine. 

I don’t understand how the data base became “corrupt” though, to me that is somewhat of a play on words, programmers and data input personnel add the criteria and create the algorithms, so how would any up to date auditing department miss the fact that the numbers and results were wrong.   I’m sure there are audit tables galore in their systems so who did not catch this sooner or was it just ignored like the happenings on Wall Street until a whistle blower came forward?  Is this some of the greed we have been hearing about? 

United Health Care Says Cheaper Efficient Doctors and Reducing Hospital Visits by the Elderly Would Help Reduce the Cost of Healthcare
AIG: You Bring the Nerds and the Algorithms and I’ll give you a AAA Rating…a little history from 1987image

Ingenix also acquired a similar type of company in Tennessee last week.  I agree we all need efficiencies in healthcare, and not turn doctors into bean counters as our President stated.  Lack of transparency and the need for money once again is creating some very strange scenarios and healthcare still trails behind cost   Sutter Hospitals just signed up with Ingenix as announced a few weeks ago for their internal program to offer physicians in the Sutter Medical Network access to performance metrics and services they can use to measure and improve medical care and delivery so here come the bean counting duties for the doctors to keep the cost down and work with additional software to accomplish this and perhaps have the potential to continue to chisel away a tiny bit more time spent with patients.  BD 

Today brings the last of a long string of Andrew Cuomo announcements about insurers agreeing to change the way they calculate payments for people who get health care from out-of-network providers.

In what the New York attorney general called the “final agreement” in the series, the insurer Health Net has agreed to stop using UnitedHealth’s Ingenix database for used to calculate “reasonable and customary” fees for out-of-network payments. The company also agreed to contribute $1.6 million toward the creation of a new database.

Cuomo says that the Ingenix database led to payments that were too low. UnitedHealth didn’t admit wrongdoing, and when CEO Stephen Hemsley testified before the Senate Commerce Committee, he defended the database. “The committee knows better than most that physician reimbursement based on nothing but the doctor’s bill is simply not economically tenable for consumers nor our health care system,” he said.

Insurers, Out-of-Network Payments and the New York AG - Health Blog - WSJ

Related Reading:

Health insurers Say “No” to limiting rescissions – Congressional Hearings

If you Lie – You Die said the Insurance Carrier (You did not report your acne)
Is This a Case for a New Law – Illegal Algorithms? How Do You Sleep at Night Rockefeller asked the CEO of United Health Care
Obama to meet with American Medical Association To Discuss Healthcare Reform – the Unknown Dollar Factor versus the Known
How Similar is Wall Street to the Health Insurance Business
The Ingenix Inquisition – Hearing Requested by Senator Rockefeller
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