New Hope for Over-Charged Health Insurance Customers

insurance case

Mary Reinbold Jerome doesn't know how much time she has left.

After being diagnosed with ovarian cancer in 2006, surgery and chemotherapy helped the Yonkers, N.Y., woman enter remission for more than a year. But the cancer recurred last October and Jerome is fighting for her life once more.

No matter how this new battle ends, Jerome said she's grateful for at least one victory: her struggles with her health insurance company will help bring about the demise of a database that critics say allowed insurers to routinely rip off patients who sought "out-of-network" care -- medical care outside of a patient's insurance company network.

While insurance companies have defended the database containing market rates for hospital procedures -- run by a company known as Ingenix -- they nonetheless have agreed to provide millions of dollars to discontinue the database and create a new, independent one in its place. Government officials told that they are optimistic that the new database will be in operation by early next year.

"I'm just thrilled, in a funny way," said Jerome. The 65-year-old woman said that at one point, her medical bills rose to $50,000 because of her insurer's stingy reimbursement practices.

"It's given meaning to my terminally ill diagnosis," she said. "It makes me feel like I fought a battle that should have been fought, even though I was at the weakest and lowest point of my life."

Insurance Companies Underpay

The database that won the ire of patients like Jerome, lawmakers and law enforcement officials is run by Ingenix, a subsidiary of health insurer UnitedHealth Group Inc.

The Ingenix database is used widely by health insurance companies to determine what the rates for various health care services should be.

But critics argue that Ingenix and the insurance companies that use it systematically underestimate the costs of services. That means consumers like Jerome are left making up the difference between what doctors charge and what insurance companies pay.

Health Insurance Reimbursements: Conflict of Interest?

The New York State Attorney General's office, in a long-running investigation of Ingenix, found that conflicts of interest "corrupted" the Ingenix database: Since Ingenix was owned by UnitedHealth, it had "a vested interest in helping set rates low, so companies could underpay patients for services," the office said.

A report by the Senate Committee on Commerce, Science and Transportation revealed last week that 17 major national and regional health insurance companies used Ingenix data to determine out-of-network reimbursements.

The report showed that "millions of Americans have been forced to pay unjustified extra charges for health insurance coverage when they go out of network," committee chairman John D. Rockefeller IV, D-W.V., said in a written statement. "This is outrageous at any time, but especially as families all throughout our country are doing everything they can to make ends meet in this economy – this is despicable."

In testimony before Congress in March, UnitedHealth Group CEO Stephen J. Hemsley said that the insurance company stood by the integrity of the Ingenix database.

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