Consumer Fraud in Health Care

Mary Jerome’s fight against Ovarian cancer started three years ago, when she sought care at a hospital outside her insurance network. She had to take on her insurance company. It’s hard enough to get the courage to fight the cancer and then to be thrown back into deep despair of thinking that your financial word has collapsed.She was stuck paying 46,000 dollars for treatment her insurance company wouldn’t cover.

I was aghast when I started getting the bills, and it took me a while to figure out what was going on. Here’s what’s going on: Insurance companies determine reimbursement for out of network care based on call what’s called usual customary and reasonable rates, or UCR. Those rates are determined by a firm called Ingenix. It turns out Ingenix is owned by United Health Group, one of America’s biggest insurance providers.

 

FRAUD


Today New York State Attorney General Andrew Cuomo called it a conflict of interest. That lowballs a medical provider’s average fees by as much as 28% forcing patients to make up the difference.I believe all these companies that have been involved with Ingenix, that there’s a very strong case that they were perpetrating consumer frauds. In a decision with national implication, United Health agreed to pay 50 million dollars to establish an independent rating agency and shut down Ingenix.

We regret that conflicts of interest were inherent in these Ingenix database products. Will patients ever get any of their money back from the insurance company?

Yes, yes, we said today is a first step, I believe consumers are entitled to hundreds of millions of dollars in reimbursements.
Mary Jerome doesn’t expect to get any money back herself. She hopes her fight makes difference for others.
Randall Pinkston, CBS News New York.

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