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Ingenix Data Base Has Some Long Reaching Legal Tentacles with Aetna, Blue Cross, Blue Shield, Humana

Posted Aug 07 2009 10:52pm

Ingenix, the technology subsidiary of UnitedHealthCare had several other health insurance companies as paying clients who used their “business image intelligence” software and algorithms to calculate out of network charges and some of those suits are just getting started.  With so many carriers being clients and now facing lawsuits, will they consider lawsuits against Ingenix, as it seems everyone turns around and sues the one who created the legal battles, healthcare is full of legal suits, way too many.

The Ingenix Inquisition – Hearing Requested by Senator Rockefeller

Who says there isn’t money to be made with software?  Business intelligence software can be very useful though when queried and used in a positive manner to locate and find areas for improvement; however there’s always that line and perhaps other side of the coin.  It appears there was money to be made from selling software to other insurers as well.  The data base used for calculations has now been retired and a non profit group is to create a replacement for use, which is probably the way it should be without any conflict of interest. 

Below you can also read about their software used to underwrite policies with the medication side of things.  Your medication records through pharmacy benefit managers are not under HIPAA, thus the company can secure a copy and sell it back to their client, i.e. another insurance company, so by using your medication trail algorithms can be run to determine your risk when a carrier is considering insuring you, and yes you are for sale.   Click on the image to visit the site and now you will see why you need Quicken Health to handle and calculate all your health charges that Ingenix has partnered with on the software, it’s not simple any more.  BD

image

A couple more notes, Sutter Hospitals in northern California works with Ingenix software 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.  Also the state of Washington granted Ingenix a $19 million, five-year contract to fight and prevent Medicaid fraud with their proprietary algorithms.  BD

Here’s what was on the web this week:

  In New Jersey with Aetna

A judge has ended two months of plaintiffs lawyers' squabbling and picked two firms to take the lead in a class action potentially worth hundreds of millions of dollars against Aetna Health Inc.

The suit accuses Aetna of knowingly using a database created by a United Healthcare Group subsidiary, Ingenix, that was rigged in the company's favor to determine how much money millions of patients and their providers would receive in "usual, customary and reasonable" reimbursements for care performed by out-of-network providers.

In California with Blue Cross

LOS ANGELES (CN) - A federal accuses Blue Cross of a wide-ranging scheme to underpay claims from out-of-network hospitals. Methodist Hospital of Southern California claims Blue Cross refuses to let it transfer patients from emergency rooms, then underpays the hospital and sticks patients with hefty bills, falsely claiming the patients "requested" to stay put.

Methodist Hospital claims that Blue Cross uses "two flawed databases or systems to determine unilaterally what amounts hospitals should charge for their services." One is the Ingenix database, for determining reimbursement amounts on out-of-state claims.

In Florida with Blue Cross Blue Shield

Blue Cross and Blue Shield of Florida was also a customer of Ingenix, according to the Senate report, "Underpayments to Consumers by the Health Insurance Industry." But the Florida insurer told Health News Florida that it used the product only in figuring dental claims.

Ingenix, based in Eden Prairie, Minn., says the company did nothing wrong. "We absolutely stand behind the integrity of our databases, the methodology used and the people who worked on them," said Karin Olson, corporate communications director.

The health plans using the Ingenix schedule enroll employees in both the public and private sectors. Those affected, according to the Senate report, include members of the military and their dependents and employees of self-funded plans at major national companies that use the insurers as administrators. Patients affected by the overcharges are believed to include many federal employees.

Where does the plan get the numbers to determine the "usual and customary charges?" The major supplier of the data is Ingenix.

In Houston with Humana

The plaintiffs seek to represent a class of thousands of persons nationwide. The proposed class would, to paraphrase the complaint, consist of all persons in the United States who, within six years before the filing of the lawsuit, were beneficiaries of employer-based Humana National Point of Service health plans and received out-of-network medical services for which Humana paid based upon the Ingenix databases.

The complaint goes on to allege that Ingenix gathers data from insurance companies and that reimbursement rates are skewed downward by the “scrubbing” of the data to remove valid high charges. According to the plaintiffs, Humana “knowingly uses inaccurate Ingenix data to determine the maximum allowable fee” and thus systematically underpays claims for the services of out-of-network providers.

Law.com - Ending Plaintiffs Lawyers' Quarreling, Judge Names Lead Counsel in Aetna Class Action

Related Reading:

Health insurer accused of overcharging millions – United Health Care/Oxford Insurance 50 Million Fine
The AMA and the California Medical Association file legal suit – WellPoint and Ingenix
Ingenix Publishes Episode Treatment Groups Methodology – Recreating themselves?
The search for John Doe – Who’s running the queries (Algorithms) and wants to know
Prescriptions risk score used to deny health insurance
Health Care Insurers Suggest Algorithms and Business Intelligence solutions to provide health insurance solution

How Similar is Wall Street to the Health Insurance Business

Is This a Case for a New Law – Illegal Algorithms? How Do You Sleep at Night Rockefeller asked the CEO of United Health Care
Andrew Cuomo – You Have to Like This Guy – Healthcare Reform
Algorithms, Formulas and Investigations leads to AARP suspending sales of some health plans
“Beware of Geeks Bearing Formulas”…Warren Buffett
How Wall Street Lied to Its Computers – Software and Programming
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