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AMA Commends N.Y. Investigation of Health Insurers
Date:2/13/2008

Remarks delivered today at a press conference hosted by New York Attorney General Andrew Cuomo to announce a suit against UnitedHealth Group, and a probe of 16 national health insurers regarding an alleged scheme to defraud consumers.

NEW YORK, Feb. 13 /PRNewswire-USNewswire/ -- The following is attributable to Nancy H. Nielsen, M.D., Ph.D., AMA President-elect:

"The investigation launched today by New York Attorney General Andrew Cuomo calls into question the validity of a system that health insurers have used for years to reimburse physicians and their enrolled members.

"UnitedHealth Group and other health insurers have shortchanged tens of millions of patients who agreed to pay higher premiums for access to their choice of physicians from outside a health insurer's network.

"These patients have a right to expect fair and accurate payment for services promised by health insurers. But at issue could be billions of dollars that health insurers have pocketed by paying treatment costs at less than what was promised.

"One way health insurers determine how much they will pay for medical services is by calculating the UCR -- a term that refers to "usual, customary, and reasonable" charges. As the name implies, these charges are essentially the "going rate" that physicians charge for their services in a given market.

"Instead of determining UCR amounts in a fair and evenhanded manner, UnitedHealth uses data that we contend pervasively understates UCR amounts. Unfortunately, there is no reason to think this is an isolated situation. In fact, the circumstances suggest that the practice of using skewed UCR amounts is widespread in the health insurance industry.

"By controlling and manipulating UCR calculations, health insurers can keep reimbursements artificially low. Health insurers have profited from skewed UCR data, while forcing patients to absorb a higher share of the costs passed on by the insurers.
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SOURCE American Medical Association
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