ADVANCE Perspective: HIM : reimbursement

Mammography and the Right to Choose

Lisa Algeo — Fri, 20 Nov 2009 17:59:00 GMT

(Editor's note: This is a guest blog written by Valerie M. Chapman, RN, MSN, a pediatric nurse for 25 years. She is a 3-year breast cancer survivor and lives in Medford, NJ, with her husband and two children.) I am a wife, a mother of two awesome kids,...(read more)

Giving Health Care a Workout

Cheryl McEvoy — Mon, 16 Nov 2009 16:13:00 GMT

Ouch. That's about all I can say (and really, all I can think) after overexerting myself this weekend. A few of my friends have been doing P90 X, an extreme workout plan that includes several videos, each of which features a different routine, i.e. abs,...(read more)

Copay Collection Dilemma

Cheryl McEvoy — Fri, 21 Aug 2009 15:54:00 GMT

(Editor's note: This is guest commentary from Lorettajo Kapinos, BSN, RN, who writes the " Tales From an ED Nurse " blog for ADVANCE for Nurses . For more information on upfront billing, read our Web article, " Cover Charge .") Most insurance companies...(read more)

Breaking Out of the PAC

Cheryl McEvoy — Fri, 05 Jun 2009 13:27:00 GMT

Medicare rules are tough to follow, even for professionals immersed in the world of coding, compliance and reimbursement. But if providers are struggling to monitor changes and understand the if-thens of Medicare policy, imagine the brain cramps lawmakers...(read more)

Database Settlement Expands Scope

Cheryl McEvoy — Mon, 19 Jan 2009 14:14:00 GMT

Health insurers are facing the costs of underpaying patients for out-of-network care. Last Tuesday, UnitedHealth Group settled an investigation by New York State Attorney General Andrew Cuomo that alleged the company's database was miscalculating reimbursement rates for patients who used out-of-network doctors. UnitedHealth agreed to pay $50 million to fund an independent database, which will be run by a non-profit group.

The case expanded last Thursday when UnitedHealth settled a class action suit filed by the American Medical Association for $350 million, according to reports. The suit raised similar questions about the allegedly faulty database.

On the same day, Aetna agreed to pay $20 million for using the database. The money will be added to UnitedHealth's $50 million to help finance the new database. Hundreds of other insurers have used the database to calculate payments, reports said.

Insurer Settles in Database Investigation

Cheryl McEvoy — Wed, 14 Jan 2009 15:29:00 GMT

UnitedHealth Group has agreed to a settlement in the investigation of its insurance database by New York State Attorney General Andrew Cuomo. According to reports, the company allegedly ran a database through its Ingenix business unit that repeatedly underpaid patients who sought care from out-of-network doctors.

Using the database to determine reimbursement, health insurers paid patients for 70 to 80 percent of the "reasonable and customary" cost of out-of-network medical care. However, according to reports, the database often underestimated fees, leaving patients to foot more of the bill. Cuomo stated that the database was allegedly receiving fee data from insurers and then supplying reimbursement information to insurers, creating a "closed loop," reports noted.

As part of the settlement, UnitedHealth will provide $50 million to fund a new database that will be monitored and controlled by a non-profit entity. According to reports, the new database is expected to save patients money in the long term. The Ingenix database will be shut down.

For more information, check out these articles from the New York Times, Associated Press and CBS News.