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Scott Shreeve, MD

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I'm the CEO of Crossover Health, a patient-centered, membership-based medical group that is redesigning the practice, delivery, and experience of health care. We offer urgent, primary, and online care to our members who can access our technology platform, practice model, and provider network from anywhere and anytime to optimize their health. Email Me



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The Price of Opacity: Lessons Learned from UNC

Opacity (ō-păs’ĭ-tē)

  1. The quality or state of being opaque.
  2. Something obscure, impenetrable
  3. Dullness of mind

I have been intrigued by the recent settlement by United with NY regarding underpayments to physicians based on faulty estimates of what constitutes a fair market rate (Ususal aNd Customer or “UNC”) for physician health services. As predicted, it has set off a rash of new lawsuits whereby physician groups are going after insurance companies with a fury, including the recently announced Cigna/Aetna lawsuits.

So what is the price of opacity? So far I have this tally (please help me add to it):

  • HealthNet – $255M with State of New Jersey
  • United – $350M with State of New York
  • Aetna – $20M to participate in new organization to set UNC
  • MVP Health – $535K to the above organization
  • Aetna/Cigna – TBD
  • TOTAL: $625M and counting

    I am pretty confident that this will top out over $1B when we are done. Nothing like a little wealth redistribution. Perhaps Bill McQuire will have to cash in on some of those back dated options in order to help the company he founded pay off their lawsuits. I guess these are the “Usual and Customary” lessons that must be learned by the health insurance ruling elite.

    I guess they figured they could play the float. In fact, this entire things reminds me of how we utilize insurance companies today. We allow them to be our transaction processors, we send them money ahead of the claim, they create mass confusion in terms of attempts to get reimbursed, which gives them time to play the “float”, and then at some point in the future they reimburse the claim.

    This entire out of network situation feels the same – Insurance companies received premiums, held onto them as long as they could, made a bundle of cash, and then ultimately after much effort ended up paying out a portion of what they actually owed.

    This is shameful. Insurance companies need to start moving up the value chain or their own opacity will be their ultimate undoing.

    2 comments on “The Price of Opacity: Lessons Learned from UNC

    1. Pingback: A Grand Illusion
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