When a new UCR database is created, how will health plans change their out-of- network payment policies?
By John Carroll Almost two years ago, Health Net signed off on a settlement of three class-action lawsuits that would have far-reaching — and very expensive — implications for the managed care industry. The health plan agreed to pay $215 million to more than 2 million members to settle accusations that its coverage of out-of-network claims was rigged in its favor. Central to the case was a database managed by Ingenix, a UnitedHealth Group subsidiary, which Health Net used to calculate the “usual, customary, and reasonable” rates providers charged for a service. Health plans often agree to shoulder a percentage of out-of-network costs based on the UCR. If the UCR for a doctor’s visit is $125, for example, the insurer might pay 70 percent, leaving the balance of the bill to the patient. Ingenix was accused of reporting artificially low UCR rates, leaving consumers to foot a larger share of the actual bill. Without admitting wrong-doing, Health Net agreed to raise payments by 14.5 percent
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