http://www.msnbc.msn.com/id/32484021/ns/health-health_care/When my husband had his heart attack we went through this problem. The paramedics resuscitated him in the field and then took him to the nearest hospital, which happened to be out-of-network for us. Of course, all the docs there were out-of-network too. To make matters worse, after they stabilized him he was rushed to another hospital (you guessed it... also out-of-network) for emergency angioplasty. he stayed there for 8 days, most of it on life support in the ICU. Imagine my surprise when the insurance company refused to pay, because my husband did not call his PCP first, did not precertify with the insurance company and had the nerve to be taken to an out-of-network hospital and be treated by out-of-network doctors.
Luckily I was able to get it all straightened out, but it took a few months. The insurance company clearly violated their own policy, which explicitly stated that emergencies such as my husband's (full-on cardiac arrest) would be covered at 100% no matter what hospital was used. It was frustrating as hell. This is one of the areas that needs to be addressed. That being said I am not in favor of throwing out the entire system because some problems exist.
From TradingMarkets.com
In a letter to Florida Insurance Consumer Advocate Sean Shaw, Insurance Commissioner Kevin McCarty said his department is investigating the use of databases provided by health information company Ingenix Inc., a subsidiary of UnitedHealth Group (NYSE: UNH). The letter did not elaborate. Office of Insurance Regulation spokesman Tom Zutell declined to comment on the investigation.
Ingenix databases used by many U.S. health insurers have been the subject of lawsuits and investigations by other state regulators.
In January, Minneapolis-based UnitedHealth said it would pay 0 million to settle class-action lawsuits over reimbursements for out-of-network services filed by the American Medical Association, state medical societies, health care providers and health planUnitedHealth also reached a national settlement with New York Attorney General Andrew Cuomo, who alleged a health-billing database run by Ingenix cheated consumers by manipulating reimbursement rates when they used health care providers outside their insurer's networks (BestWire, Jan. 13, 2009). That settlement, filed in federal court, included an agreement to close two Ingenix databases and pay million to a nonprofit organization, which will establish a new, independent database.
In June, Health Net Inc. (NYSE: HNT) agreed to stop using Ingenix reimbursement databases and to pay .6 million toward the database fund under an agreement with the New York attorney general. In all, New York received 0 million from 12 health insurers for the database in what Cuomo called a "corrupt reimbursement system" (BestWire, June 19, 2009).
A UnitedHealth spokeswoman did not immediately respond to messages seeking comment.