Insurers Accused Of Underpaying Patients

CBS Evening News: New York AG Investigates Whether Health Care Companies Perpetuated Fraud

(CBS)  Mary Jerome's fight against ovarian cancer started three years ago when she sought care at a hospital outside her insurance network. She also had to take on her insurance company, reports CBS News correspondent Randall Pinkston.

"It's hard enough to get the courage to fight the cancer and then to be thrown into despair of thinking your financial world has collapsed," Jerome said.

She was stuck paying $46,000 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," she said.

Here's what was going on: Insurance companies determine reimbursement for out-of-network care based of 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.

On Tuesday, New York state Attorney General Andrew Cuomo called it a conflict of interest that lowballs a medical provider's average fee by as much as 28 percent.

"These companies that have been involved with Ingenix, there is a very strong case that they were perpetuating consumer frauds," Cuomo said.

In a decision with national implications, United Health agreed to pay $50 million to establish an independent rating agency and shut down Ingenix.

"We regret that conflicts of interest were inherent in these Ingenix database products," said United Health Group attorney Mitchell Zamoff.

"As for cheated consumers, will they ever get any of their money back from the insurance companies?" Pinkston asked Cuomo.

"Yes, yes," Cuomo said. "We said today is the first step. I believe consumers are entitled to hundreds of millions of dollars in reimbursement."

While Mary Jerome doesn't expect to get any money back herself, she hopes her fight will make a difference for other patients.

[tincup356]

To IndepTex;
Unfortunately we don''''t have a very responsive Congress to the average persons needs. So what may have to happen, as bad as it sounds, is some sort of citizen revolution and it may need to be in a violent form to get attention. Most Americans have just learned to take the S-h-i-t doled out to them and not get involved other than ******** to friends about problems. It does take real action to get change. I mean look what change two planes in the WTC brought! I have a little hope the Obama Admin. will bring necessary change but I am not optimistic Congress will go along.

Posted by endrepubs at 02:23 PM : Jan 14, 2009,,,,,,,,,,,,,If people are waiting on congress for help they might as well give up....Its been three months since they hollered we need to bailout the home foreclosure problem,,,and they were given money to do just that.....then paulson went the other direction,,and gave it to the banks and AIG,,,,,,you cannot trust our government to do anything that will benefit the people,,,,they are nothing more than white collar ,suit and tie terrorists robbing the country and committing treason.

[tnz650-2009]

"Also, here, everyone pays the same and receives the SAME care. The BEST care. The rich don''''t get better care because they have more money." - Posted by erasmus606 at 01:05 PM
"Here, the government is for the average person, not just the billionaire. The government listens to what the PEOPLE want. They are working for US." - Posted by erasmus606 at 12:59 PM

And what country did you say you came from?

[tnz650-2009]

If the price of oil goes back up there are a number of middle eastern countires like Dubai, Saudi Arabia, Kuwait. Then there are also european countries and Japan. If China keeps going capitalist there will also come a time where good doctors are so in demand they will be able to ask any price they want, and will get it. Posted by getoffmine1 at 12:17 PM

You think there''s going to be a flood of American Doctors clamoring to move to a middle eastern country just in order to make more money? Would YOU? Seriously, even with all the problems facing our country today, you couldn''t pay me enough to move to Dubai, Kuwait or China. And there isn''t anywhere in Europe that will ever pay more (on average) for doctors and Japan wouldn''t allow the flood. If you''re the type of person that would leave America to follow a buck, then as far as I''m concerned - good riddence! It would never amount to more than a drop in America''s talent pool of Doctors anyway. Never!

[erasmus606]

Posted by endrepubs at 01:15 PM : Jan 14, 2009

Your NEW government needs to ELIMINATE all the greedy insurance companies and start all over.:)

Easier said than done, I know.

[erasmus606]

Also, here, everyone pays the same and receives the SAME care. The BEST care. The rich don''t get better care because they have more money.

[erasmus606]

How does Canada keep from coming under the thumb of the Billionaire class that is ruining the US?

Posted by jbrown88881 at 03:53 AM : Jan 14, 2009

I think the better question is how did the "Billionaire class" gain control of you?

Here, the government is for the average person, not just the billionaire. The government listens to what the PEOPLE want. They are working for US. We don''t have private hospitals because WE don''t want them private. We don''t allow everyone to have guns, because WE (the people), don''t want it that way.:)

The other thing is that we are very careful about who we vote in as "President".

[getoffmine1]

I wish i was a doctor. I don''t do to bad but don''t make anything near doctor money. You say there are all of these new doctors coming out of medical school. Where are they practicing, certainly not around my area. As far as extravagant pay, someone should make whatever they can make as long as they are truely providing a product of service based on supply and demand. The fact is there are not enough doctors to treat all of the people in the U.S. that need medical care. Therefore the rates are high, those that can pay will (meaning better health plans) those that cannot have to settle with what they get.
I''m not saying I like the situation but it is what it is. When people start pointing at others saying they make to much money and should have to do their job for less, it is not fair.
That is not to say there are not situations where people really are making to much, like oil execs ect. But in these cases the market was manipulated to yield higher profits. This si not the case with the medical profession, the more the population grows the more demand will grow, and the schools are producing less doctors

[getoffmine1]

You say doctors will move somewhere with higher pay. Where on earth will they go??? If they decide to leave America to get higher pay, they will have to move to a country that has universal care unless they want to go to some 3rd world country and work for barter or free. Think before you post such nonsense.

Posted by endrepubs at 12:09 PM : Jan 14, 2009

also i live in the Philadelhia area. Because of lower pay and the cost of malpractice insurance doctors have been leaving, some to relocate and many who just said screw it, I''m a millionaire I''m done with the B.S.
They are recruiting nurses in alot of hospitals to do what doctors used to do, and it is costing lives. I know, two people close to me are RNs. I hear about it all of the time. Once again most people will not do a difficult job, no matter what it means to society, unless they are being paid what they think they deserve.

[getoffmine1]

You say doctors will move somewhere with higher pay. Where on earth will they go??? If they decide to leave America to get higher pay, they will have to move to a country that has universal care unless they want to go to some 3rd world country and work for barter or free. Think before you post such nonsense.

Posted by endrepubs at 12:09 PM : Jan 14, 2009

If the price of oil goes back up there are a number of middle eastern countires like Dubai, Saudi Arabia, Kuwait. Then there are also european countries and Japan. If China keeps going capitalist there will also come a time where good doctors are so in demand they will be able to ask any price they want, and will get it.

[getoffmine1]

since when is health care a right? I could agree with your argument for those under 18 but once you are 18 you have options to get coverage, wether it is working at McDonalds or going inot the military there are options.
If the gov''t gets involved there will be more problems. One they will become even more intrusive telling people what they can and cannot do. If you have good health coverage and choose to smoke, drink, eat fatty foods ect, it is your right, you pay for your health coverage. Once the govt'' starts paying they will tell everyone you must do this, you cannot do that. That is not what America is about.
Also they will have to tax everyone at a different rate. If my HHI is $125,000.00 per year and I have blue cross blue shield, why would I want to pay more in taxes then I am paying for my coverage now when I would get inferior coverage, just to cover lower income earners who previously had no coverage?

[solopov-2009]

I have top insurance that I pay a high premium for and the insurance companies still try to nickle and dime me on everything. I am worried constantly when I bring my kids in for care because I know I will get some type of denial letter or short payment because I did not fill out a form in triplicate, with a bill attached. This system does not work!!! The argument of doctors leaving because they will not make enough money is garbage. We are getting kicked in our teeth by insurance companies and so are they. Health care is right for every person, no matter what age. It seems to me that if we invest more in our health care we would be a more productive company. Private companies do it all the time. They invest in wellness programs etc. We have to stop looking at this subject as a unaffordable cost and we have to start looking at it an investment in our future. I already pay a ridiculous amount of taxes for nothing. I would feel better knowing that people out there are getting the care they deserve as human beings while sharing my money with Uncle Sam.

[solopov-2009]

I have top insurance that I pay a high premium for and the insurance companies still try to nickle and dime me on everything. I am worried constantly when I bring my kids in for care because I know I will get some type of denial letter or short payment because I did not fill out a form in triplicate, with a bill attached. This system does not work!!! The argument of doctors leaving because they will not make enough money is garbage. We are getting kicked in our teeth by insurance companies and so are they. Health care is right for every person, no matter what age. It seems to me that if we invest more in our health care we would be a more productive company. Private companies do it all the time. They invest in wellness programs etc. We have to stop looking at this subject as a unaffordable cost and we have to start looking at it an investment in our future. I already pay a ridiculous amount of taxes for nothing. I would feel better knowing that people out there are getting the care they deserve as human beings while sharing my money with Uncle Sam.

[getoffmine1]

You do realize that according to the story above that is EXACTLY what insurance companies are doing, right?

Posted by omega40 at 10:02 AM : Jan 14, 2009

Yes, but if the gov''t starts regulating prices so every person in America can get whatever care they need the rates will have to be cut much deeper then the negotiated rates. Again there will come a point where alot of doctors either move somewhere with higher pay or they will just retire with their money and not deal with the stress and low balling. Again most people do not choose a career to do the right thing, they do it to make as much as they can. Doctors are not going to just accept the fact that they will no longer be able to afford thier mansions, shore houses and 4 times a year exotic vacation fancy cars ect. They have been taught that this is what they deserve. They provide a service we all need, so they feel they deserve much more then the average white collar person, what the rest of us do is not as important.

[getoffmine1]

The problem that Canada has, is that many of it''''s doctors came here to practice medicine, because our greedy for profit system can REALLY enrich them beyond what the Canadian system can do.

Posted by hungry684 at 10:04 AM : Jan 14, 2009

Exactly and if they start making less here they will go somewhere else. I''m not happy about the situation but in America money talks. If someone has the gumption and intelligence level to complete med school chances are they can learn to do pretty much whatever they want, they are not every day joes like most of us. Another post mentioned that Dr.s make areound $200,000 per year. You can make more then that in top professions like law, engineering ect. Sure there will be a few people who do it because they love the profession, but our culture has been teaching people to go where the money is, you cannot change peoples attitudes after they have had the greed is good mentality force fed to them for the last 28 years.

[amrt5016]

This is exactly why we need a "universal", government controlled health care system.

This "for profit" system only robs the patient.

Eliminating the greedy corporate middle men, will save TRILLIONS per year. Pay the provider directly, let the government regulate price controls THAT ARE FAIR, and everyone will benefit - EXCEPT the HMO''''s.
Posted by hungry684 at 08:53 AM : Jan 14, 2009

The health care delivery system in the U.S. is expensive and inefficient. That''s reason enough to switch to the system that exists in Europe and other countries. In the same vein, we need to overhaul our educational system to produce high levels of literacy and technical skills in our labor force.

The world has caught up to the U.S. in many respects. It''s time we adopted the systems that work best for them.

[xyzme1]

Posted by the74blaster at 12:01 AM : Jan 14, 2009

I have no clue why she touts it so much...I was just studying up a comparison of the US health care system and the Canadian one....which are having many of the same problems....


She touts it because it is better than ours. The World Healthcare Orginization ranks Canada 30th and the US 37th out of 190 countries.

http://www.photius.com/rankings/healthranks.html

Columbia, Costa Rica, Portugal... these are just a few of the countries that rank higher than the good ole USA

[omega40]

I''''m not sticking up for the insurance cos, but the problem wuth your idea is this. If the gov''''t controls cost doctors will start making less money. If they cannot make as much, they will decide to persue other higher paying professions that require less schooling. Why go through med school if you can make more as a business consultant or lawyer? Doctors do what they do for the money in most cases.

Posted by getoffmine1

You do realize that according to the story above that is EXACTLY what insurance companies are doing, right?

[getoffmine1]

This is exactly why we need a "universal", government controlled health care system.

This "for profit" system only robs the patient.

Eliminating the greedy corporate middle men, will save TRILLIONS per year. Pay the provider directly, let the government regulate price controls THAT ARE FAIR, and everyone will benefit - EXCEPT the HMO''''s.

Posted by hungry684 at 08:53 AM : Jan 14, 2009

I''m not sticking up for the insurance cos, but the problem wuth your idea is this. If the gov''t controls cost doctors will start making less money. If they cannot make as much, they will decide to persue other higher paying professions that require less schooling. Why go through med school if you can make more as a business consultant or lawyer? Doctors do what they do for the money in most cases.

[missingamerica]

But...but...but they needed the money to buy legislation to make car insurance mandatory and pass smoking bans that are really half-fire prevention laws and require wearing seat belts and fund "America is FAT!" studies...

All of which contributes to lowering their costs and and increasing their profits...

Which you have noticed in the much reduced insurance bills you now receive, no?

[babooph]

For many years insurance claims are done overseas by computer ,with the operators paid a percentage of what they "disallow"-the US propaganda system has been directed to hide this fraud.