Sen. Jay Rockefeller, chairman of the Senate Commerce, Science and Transportation Committee, wants answers at a hearing Tuesday from the chief executives of UnitedHealth Group Inc. and its subsidiary Ingenix Inc., a claims database used by insurers nationwide to calculate out-of-network rates.
The inquiry follows lawsuits and an investigation by New York Attorney General Andrew Cuomo alleging that UnitedHealth and Ingenix manipulated rate data so insurers had to pay less and patients more for out-of-network services.
More than 70 percent of workers who get health care through their employers are enrolled in plans that allow them to go out of network, according to the Kaiser Family Foundation. Typically, those plans will pay a set percentage, say 70 percent, for an out-of-network visit.
But unknown to many consumers, when patients go out of network, their plan doesn’t actually pay 70 percent of the doctor’s visit cost. It pays 70 percent of what it determines is the “usual, customary and reasonable” cost for the procedure or doctor’s visit in question.
Insurance companies determine that cost themselves, and there’s scant regulation or oversight of how they do it.