Daily Skiff

More than 500 students and alumni will receive reimbursements from the university-provided health insurer Aetna after New York Attorney General Andrew Cuomo found that the claims system had not been receiving the frequent updates it needed.

The reimbursements for the 517 TCU students and health care providers will total more than $34,000, but this amount represents a small portion of the total claims for the university, said Marilyn Hallam, coordinator of the Brown-Lupton Health Center office.

"When you put paper and pencil to that, it turns out to be about one-third of one percent of total claims," Hallam said. "Most of those students or providers are going to be getting in the neighborhood of $25 to $32."

Aetna will reimburse the health insurance claims of more than 73,000 students and 20 colleges nationwide, according to a news release issued by Cuomo's office on Feb. 2.

Hallam said the reimbursements would go to students who received care from out-of-network providers, or providers that weren't on Aetna's list of preferred provider organizations (PPOs).

"With PPOs your insurance has negotiated rates with physicians for a variety of patient interactions," Rae said. "If you decide you don't want to see someone on the PPO list you would go to an out-of-network provider."

Aetna must allot the reimbursements because it had been using an outdated Ingenix software system, Hallam said.

Dr. Mary Rae, director of Health Services, said the flaw in the Ingenix system arose because it under-calculated the reimbursements for these out-of-network cases.

Hallam said the software determines what the market fees are for insurance companies to decide what they are going to pay.

Hallam said UnitedHealthcare owns Ingenix, and will pay $50 million to revamp the system. But many other insurance companies, including Aetna, who will contribute $20 million, will pitch in as well, she said.

"Once they develop that new software they will stop using Ingenix altogether," Hallam said.

Under the agreement with the attorney general, Aetna will pay more than $5 million, plus interest and penalties, for claims involving out-of-network care, according to the news release.

Also under the agreement, Aetna Student Health's claims processing system must be updated frequently, the company must hire an independent third-party examiner and provide enhanced training to all Aetna employees and subsidiaries, according to the news release.

However, tracking down those who qualify for the reimbursements is difficult because it covers students from 1998 to present, she said.

"If they've graduated back in '98 or '99, it's a matter of now having to find those people," Hallam said.

Hallam said Aetna will work hard to locate the people receiving reimbursements.

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