A class action complaint filed last week on behalf of non-contracted ASCs across the country charges UnitedHealth and other health plans of misusing the Ingenix Database to under-reimburse ASCs by millions of dollars over the last decade. Health insurers throughout the country use the Ingenix Database to determine the "usual and customary" reimbursement rate to pay ASCs that are not contracted members of their network.
"ASCs all across the country have been harmed by the Defendants’ failure to adequately pay for outpatient surgery services," reads the complaint.
UnitedHealth owns and operates the Ingenix database it uses to determine reimbursement rates and thus "has a financial incentive … to reduce the amount reimbursed for out-of-network services provided to its plan members," reads the complaint. Other health insurers "have a financial incentive to manipulate the data they provide to the Ingenix Database so that the pooled data will skew reimbursement rates downward."
"We have reason to be believe [the database] doesn't exist for ASCs, but I’m not sure. If it does exist, it contains flawed data," says lawyer Daron Tooch of the Los Angeles firm of Hooper, Lundy & Bookman. "We believe that the flawed data in the Ingenix database, and the payors’ improper manipulations of that data, are major causes of unreasonably low amounts of reimbursement to ASCs."
Every non-contracted ASC will be part of that class unless they opt out of the class, says Mr. Tooch, adding that the class could number in the hundreds, perhaps thousands.
ASCs that don’t have written contracts with health plans are said to be "out of network." These ASCs receive fewer patients from the plans, but they’re not required to accept reduced amounts on their charges. Plans pay the nonparticipating ASCs based upon a percentage of the usual and customary charges by ASCs for those non-covered procedures. For example, Downey Surgical Clinic in Downey, Calif., which filed the class action on behalf of all affected ASCs, charged $12,664.95 for an EGD (with possible biopsy) performed in 2007. The patient’s plan covered 50% of charges, but United Health only paid $382.90 (3%). So low are some out-of-network payment rates that many ASCs have been forced to accept low contracted rates, says Mr. Tooch.
Ingenix databases — used by many U.S. health insurers — have been the subject of lawsuits and investigations by other state regulators. In January, UnitedHealth agreed to a $50 million settlement with the New York attorney general and a $350 million settlement with the AMA, covering conduct going back as far as 1994.
—Dan O’Connor
