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Life Health > Health Insurance

Garden State Eyes Insurer Shift To Medicare Price Data

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The New Jersey Division of Insurance wants to free health carriers from having to rely on health care price data supplied by a unit of UnitedHealth Group Inc.

New Jersey insurance regulators have proposed a change in insurance regulations, in Proposal Number 2006-405, that would let carriers use price data from the federal government rather than from the UnitedHealth unit when determining benefit amounts for patients’ visits to out-of-network doctors, clinics and testing facilities.

Up till now, most Garden State health carriers have based reimbursement for claims for care from out-of-network “non-hospital providers” on Prevailing Healthcare Charges System price data.

The price figures come from Ingenix, Eden Prairie, Minn., a unit of UnitedHealth, Minnetonka, Minn.

Today, many health carriers in New Jersey are using or want to use the Resource Based Relative Value Scale data collected by the Centers for Medicare and Medicaid Services, New Jersey officials write in the administration change proposal.

One problem, for patients and out-of-network doctors, is that the RBRVS fees tend to be much lower than the PHCS fees, officials write.

But Medicare does let members of the public see the RBRVS data, while Ingenix does not let members of the public see the PHCS data, officials write.

Shifting to use of the RBRVS data “would enable covered persons to access the schedule and determine the dollar value of their benefit and the net amount they would owe to the out-of-network non-hospital provider prior to obtaining services,” officials write.

The New Jersey proposal would permit health carriers to shift to the RBRVS fee data, but it would require the carriers to set the allowance for out-of-network non-hospital provider services to at least 150% of the current RBRVS amount.

The member’s coinsurance for out-of-network non-hospital provider services could be no more than 40% of the carrier’s allowed charge based on the RBRVS amount, according to the text of the proposal.

A carrier also would have to offer at least one plan that calculates out-of-network non-hospital provider benefits using the PHCS system.

A copy of the proposal is on the Web at Document Link


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