NYS Medical Society Applauds AG Cuomo’s Lawsuit vs United Healthcare for Fraudulent Business Practices

LAKE SUCCESS, NY (02/13/2008)(readMedia)-- Robert Goldberg, DO, President of the Medical Society (MSSNY) of the State of New York made the following comments today at NYS Attorney General Andrew Cuomo’s press conference at which he announced his intention to sue United Healthcare companies. The suit will allege that the companies engaged in “fraudulent, deceptive and illegal business practices” in setting rates for paying patient subscriber’s out-of-network physicians.

“My name is Dr. Robert Goldberg. As President of the Medical Society of the State of New York, I am pleased that the New York Attorney General Andrew Cuomo’s Office is investigating United Healthcare. The flawed methodology that United uses to pay claims to subscribers who have chosen to see out-of-network physicians has been a matter of great concern to the Medical Society for several years. In fact, MSSNY has been involved in litigation with United since 2000.

United Healthcare, through its wholly-owned subsidiary, Ingenix, has fostered an institutionalized practice of determining payment using faulty data that is not subject to external oversight or audit. Despite MSSNY’s repeated expression of concern regarding the lack of integrity of its data, Ingenix still does not internally audit or exert standard quality measures over the data.

United’s indefensible practices damage not just physicians, but patients and their employers. Insurers charge higher premiums to subscribers who wish to see out-of-network physicians of their choice. These out-of-network physicians did and do not agree to accept discounted payments, and no amount of bullying by United can change that fact.

United sold these policies to subscribers with the promise that it would pay its full share of the physicians’ “usual and customary charge.” The Medical Society believes that United and United HMO failed to pay the promised amount. While collecting higher premiums for the option to see any doctor they chose, United failed to deliver the promises that supposedly justify the higher premiums. In turn, patients were then obligated to pay the balance of the medical bills after United refused to pay the claims properly. This behavior left United’s own subscribers out in the cold when they were looking for proper reimbursement under the terms of their policy.

United’s defective practice had a devastating affect on millions of New Yorkers who were covered under the Empire Plan. Subscribers were told that repayment was based on “independent research” in the hope that it would discourage them from further challenging the meager payments. When the patients and physicians asked United to explain the basis of its calculations, United refused. United claims its data was confidential and proprietary and could not be examined. United’s attitude is, “I won’t show it to you, but believe me, it’s good.”

Unless, we can see it and ensure its validity, we don’t want secret data used in New York.

Far from being independent, the data comes from United's own wholly owned subsidiary, Ingenix. Ingenix (and United) make profits from selling the data to other insurance payors, which then also use it for New York patients and physicians. United's secret black box is the foundation for virtually all insurance payments in New York. The lack of external oversight and audit, and Ingenix's demonstrated indifference to fixing known defects in the database, justifies the Attorney General's concern. We are pleased to support his investigation in any way we can.

Once payments to physicians become valid and reliable, our patients can once again participate in an educated selection of physicians who best suit their healthcare needs and those of their families. As we know, New York has the best-trained physicians in the world, and our patients should have access to all of them, not just the ones in their particular networks.

The Medical Society of the State of New York applauds Attorney General Cuomo and his hard-working staff for their diligent efforts in moving forward in an investigation that we believe will have long term benefits to healthcare in New York. MSSNY also applauds the Attorney General for acting on the complaints of our patients of our physician members.”

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