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If insurers pay more, will patients pay less?


Attorney General Andrew M. Cuomo's assault on health insurers' out-of-network payments  could lead to lower out-of-pocket costs for consumers.

   The state's top law enforcer is taking on the powerful health insurance industry, challenging its use of oft-criticized data supplied by a division of No. 2 insurer UnitedHealth Group to determine how much to reimburse for out-of-network care.


Cuomo says the data, which originally comes from insurers nationwide and is then processed and spit back out by UnitedHealth's Ingenix unit, understates so-called "usual and customary rates" for medical care. As a result, he says consumers and doctors have been ripped off for years.

   He's already forced UnitedHealth to admit the conflict of interest, abandon the databases and spend $50 million to help set up an independent, nonprofit service to do the same job. He also forced Aetna to pay $20 million toward the same goal. And on Wednesday, he forced MVP Health Care of Schenectady to sign on, contributing $535,000 to the cause.

   At the same time, he announced plans to sue Capital District Physicians Health Plan for resisting, and gave notice that insurers can either cooperate or face litigation. HealthNow New York, Independent Health Association, and Univera Healthcare parent Excellus BlueCross and BlueShield are now negotiating with him.

   If everything works as Cuomo says he intends, a nonprofit medical institution, probably at a university in New York State, will run a new database of usual and customary rates, which he says will be fairer and more transparent to doctors and consumers.

   The only question will be just how much consumers really save in the end.

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