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Texas Joining the Ingenix Inquisition with Introducing Bill for New Penal Codes – Fraud Against Practitioners

Posted Apr 17 2009 11:50pm

This is right from the web page of Rep. Allen Vaught in Texas.  He is introducing a bill and is asking for thoughts and information.  If you are a image physician in Texas and have any input you want to add, there’s an email listed to contact him.  Recently the AMA, State of California, Georgia have already filed suit on this.  In New York, Attorney General Andrew Cuomo won a settlement and the company, a subsidiary of United Health Care has agreed to disband the use of the data base.  

This is a type of business intelligence software that was used to create balance billings based on what was called customary charges and that is the area of conflict lies.  The Senate recently heard testimony from the CEO of United Health Care on the issue as well which over charged individuals and contributed to balance billings.  By the way, they also sell medical records software in addition to running complex analytical formulas, but you would be the better judge here on where you store might want to store patient medical records and who’s algorithms you purchase.  Something else of interest below where our medication trails are bought and sold and how Ingenix supplies this information to insurance carriers to deny and approve claim requests.  BD 

“Milliman Intelliscript, part of the Milliman Company, collects data from Pharmacy Benefit Managers (PBMs) that are not covered by the Health Insurance Portability and Accountability Act of 1996. Then insurance companies pay a small fee to obtain the data, which they use to deny or approve claim requests.”

Ingenix, a Minnesota-based health information services company that had $1.3 billion in sales last year -- and Wisconsin-based rival Milliman -- say the drug profiles are an accurate, less expensive alternative to seeking physician records, which can take months and hundreds of dollars to obtain.”

Anyway, more information is located at the link below on the legislator’s web site.  BD 

In Texas, approximately 25 health insurance carriers use a database created by Ingenix, Inc. to determine out-of-network reimbursement rates for consumers and payments to practitioners. Investigations in other states have determined that many health insurance companies who use these schedules compiled by Ingenix to determine reimbursement rates for out-of-network care, have understated the market rate by up to 28 percent. Since Texas insurers use this same database, it is likely that a large proportion of Texas consumers and practitioners are losing money.

In response to this fraudulent practice, I filed House Bill 4385, which will create a new section of the Penal Code entitled “Fraud Against Practitioners .” The bill states that an offense occurs if a person (or company) utilizes a database they knew or should have known contains inaccuracies, and if proof of intent to deny or diminish payments can be shown. In this economic climate, such deceptive practices are completely unacceptable since they drive up health care costs for both consumers and practitioners.

I welcome your thoughts and ideas regarding the bills I have filed for the 81st legislative session. Keep in mind that these are the bills as introduced and that details are subject to change as part of the legislative process. Please email my office at District107.Vaught@house.state.tx.us with the subject line 81st Legislative Session Bills.

Bills filed for the 81st legislative session (part three) | pegasusnews.com | Dallas / Fort Worth

Related Reading:

The 2 New Hot Words in Healthcare: Algorithms and Whistleblowers

Doctors fight balance-billing ban on out-of-network costs to survive
Will Greed lead to Meltdown of the Health System?
“Beware of Geeks Bearing Formulas”…Warren Buffett
The AMA and the California Medical Association file legal suit – WellPoint and Ingenix
Health Insurance Underwriting procedures – Data Mining to Cherry Pick and some are listed on the Web
The search for John Doe – Who’s running the queries (Algorithms) and wants to know
The Ingenix Inquisition – Hearing Requested by Senator Rockefeller
Andrew Cuomo – You Have to Like This Guy – Healthcare Reform
Prescriptions risk score used to deny health insurance
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