Two more insurers yield to Cuomo Jonathan D. Epstein The Buffalo News, N.Y. McClatchy-Tribune Regional News

Mar. 6--Excellus Health Plan, parent of Univera Healthcare, and Albany- based Capital District Physicians Health Plan surrendered Thursday to pressure from state Attorney General Andrew M. Cuomo, agreeing to stop using controversial databases and pay millions of dollars to reimburse consumers.

In dual settlements with Cuomo, both health insurers agreed to abandon the data bases that the entire health insurance industry has been using for years to determine how much to reimburse providers and consumers for out-of-network medical care.

The databases, operated by UnitedHealth Group subsidiary Ingenix, contain data from around the country on "usual and customary rates" that providers charge for a range of services and procedures. Insurers use this data and then typically reimburse between 50 and 80 percent of that rate.

In addition, Excellus will pay $775,000 and Capital District will pay $300,000 to support the creation of a new, independent database to be run by a nonprofit institution, which Cuomo hopes to locate at a university in New York state. Both companies agreed to start using the new database once it is set up, which Cuomo hopes will be completed in six months.

Also, both insurers will reimburse consumers who were not adequately compensated during the last six years, which is the statute of limitations for this case.

Consumers who have out-of-network coverage from either of the two carriers and believe they were underpaid can submit documentation from prior years. Both companies will review that material, following stipulations set by the state, and will reimburse them if the claims show underpayments.

Both companies' processes will be supervised by Cuomo's office, which will also post information on its Web site so consumers will know when it will start. Cuomo said the effort should be underway over the next several weeks.

"I think it's fair. I think it's the right thing," Cuomo said in a telephone press conference. "I applaud Excellus and [Capital District] for agreeing to this settlement, for honoring their commitment, because this was their commitment. This is what the contract said. This is what the patient paid for."

Capital District serves 29 counties, and had about 1,300 people with out-of-network coverage, largely in Albany's Capital District.

Excellus serves a total of 2 million people in 39 counties of Upstate New York, including 170,000 in Western New York through Univera. About 880,000 had out-of-network coverage, though it's not clear how many might be eligible for money.

Cuomo said there is still one company remaining that operates in the state and hasn't settled, but he wouldn't identify it. However, the notable missing player so far is New York Citybased Emblem Health, parent of Group Health and Health Insurance Plan of New York.

jepstein@buffnews.com
Copyright (c) 2009, The Buffalo News, N.Y. Distributed by McClatchy-Tribune Information Services. For reprints, email tmsreprints@permissionsgroup.com, call 800-374-7985 or 847-635-6550, send a fax to 847-635-6968, or write to The Permissions Group Inc., 1247 Milwaukee Ave., Suite 303, Glenview, IL 60025, USA. Mar. 6--Excellus Health Plan, parent of Univera Healthcare, and Albany- based Capital District Physicians Health Plan surrendered Thursday to pressure from state Attorney General Andrew M.