The News Journal

By JONATHAN STARKEY • The News Journal • April 16, 2011

Blue Cross Blue Shield of Delaware violated state law by signing a contract with a company that guaranteed the health insurer would save money by denying high-tech imaging tests such as nuclear cardiac exams, according to findings of an investigation by Delaware's Department of Insurance.

MedSolutions was hired in July 2009 to review claims before doctors administered tests such as knee MRIs and CT scans of the brain. The firm stood to lose money if it did not reach its 20 percent savings target, according to the report. Such a contingency violated state law. It was removed from the contract last summer.

The report, which took 13 months to complete, also criticized BCBSD and Tennessee-based MedSolutions for making it difficult for high-risk heart patients to obtain nuclear stress tests, which doctors use to diagnose artery blockages. MedSolutions denied 27 percent of requests to pay for nuclear stress tests -- 24 percent when considering those overturned on appeal. Under Blue Cross Blue Shield's pre-authorization program, the insurer forced doctors to prove a test was needed before it would agree to pay. 

Insurance Commissioner Karen Weldin Stewart said she is still considering whether to assess a fine or impose other penalties because of the illegal contract clause. 

As Stewart's report surfaced Friday, so did a summary report concluding a parallel probe of preauthorization in Delaware by the U.S. Senate Committee on Commerce, Science and Transportation. It reviewed pre-authorization programs at BCBSD and at Aetna. 

The report blamed insurance companies and doctors for confusion that often left patients stuck in the middle unable to access necessary care. Senate investigators focused on Michael Fields, an Elkton, Md., man whom The News Journal profiled in March 2010, sparking the probe.

Fields was denied nuclear tests two times in January 2010 before his doctors admitted him to Christiania Hospital and performed bypass surgery. 

"In the case of Michael Fields, the pre-authorization process unnecessarily delayed care for his life-threatening medical condition," the Senate report said. 

The Department of Insurance report recommends that Blue Cross implement pre-authorization standards no stricter than those recommended by the American College of Cardiology and other organizations. That recommendation resulted from findings in the report by Dr. Marc Tecce, a cardiologist at Thomas Jefferson University hired by the Department of Insurance to review BCBSD records. He said MedSolutions' standards for approving nuclear stress tests were stricter than those developed by the ACA, the American Heart Association and the American College of Radiology. He said the MedSolutions standards were inappropriate for high-risk patients.

Stewart said she intends to write a regulation compelling insurance companies to abide by those criteria.

"I feel very strongly that the criteria that the American Cardiology Foundation uses are the criteria that should be used," Stewart said. "We're not going to [let] grass grow under our feet on that one." 

BCBSD said in response to the report that it is inappropriate for Stewart to impose a set of criteria. 

"The health and safety of our members are vitally important to us," the statement read. "We implemented our high-tech imaging pre-authorization program to ensure our members have timely access to high-quality, safe and appropriate medical care, while minimizing the potential for duplicative and unnecessary tests." 

The insurer no longer requires pre-authorizations for nuclear cardiac exams, although MedSolutions still does that for MRIs and CT and PET scans.

Aetna, which also contracts with MedSolutions, still requires prior approval for nuclear cardiac scans. 

Later problems
Tecce's review also found that 16 nuclear exams that were denied should have been approved. Another 17 exams that were denied but overturned on appeal should have been cleared without issue. That means 12 percent of denials were inappropriate. Another 43 were denied for administrative purposes, such as insufficient information or a scan ordered without a doctor having seen the patient in more than 30 days. 

Four Delaware patients who were denied a scan submitted a serious cardiac claim within about a month, according to Stewart's report. Those claims would be for services such as a cardiac catheterization in an emergency department of a hospital or bypass surgery to clear life-threatening blockages. Stewart said that number did not present an "alarming concern."

Fields was one of those patients. 

"You're talking about somebody's life," Fields said Friday. "You're literally putting a price tag on somebody's life. You can't do that." 

Contract 'obnoxious'
Dr. Timothy J. Gardner, medical director for Christiana Care's Center for Heart & Vascular Health, called the 20 percent savings provision in the BCBSD-MedSolutions contract "obnoxious." If it failed to hit the target, MedSolutions had to refund 10 percent of its fee. 

"That's not right," Gardner said. "I think that's based on the assumption that the doctors aren't providing good care and are doing unnecessary tests."

The guaranteed savings provision was stripped from Blue Cross Blue Shield's contract with MedSolutions last summer, during the state's examination. 

"There is absolutely no financial incentive whatsoever for the MedSolutions doctors and nurses who review these requests to do anything other than make sure that patients receive the safest and most appropriate tests for their needs," Dr. Gregg Allen, chief medical officer at MedSolutions, said in a statement. 

Allen contended that specialists who own testing equipment often order expensive tests like nuclear stress exams unnecessarily, noting that cumulative radiation exposure can be harmful to patients. 

A 2009 study by the American College of Cardiology and the insurer UnitedHealth that looked at almost 6,000 nuclear cardiac exams found that 14.4 percent of the scans were ordered inappropriately, based on the college's published guidelines. According to the insurance department data, which considered only requests submitted to BCBSD, more than one in 10 nuclear exams doctors ordered did not follow ACC criteria, the Senate report noted.

In a June 2010 report, the Medicare Payment Advisory Commission said a rapid increase in imaging has correlated with a shift in imaging from hospital settings to doctors' offices. 

The Senate report fo- cused on the competing conflicts of doctors and insurance companies.

"A predictable result of this conflicted health care delivery system is that patients like Michael Fields and countless others do not reliably receive medically necessary services in a timely way, or they receive unnecessary -- or sometimes even harmful -- services," the Senate report said.

'Close to death'

Fields' ordeal began in January 2010, when he visited his primary-care doctor, Bruce Turner, of Newark, complaining of chest pain. Turner ordered Fields' first denied nuclear cardiac exam on Jan. 6.

Turner's secretary, Mary Wingate, handled the appeal with MedSolutions and ultimately, MedSolutions denied coverage in writing on Jan. 15, saying a staff physician, Dr. John Schottland, a neurologist, had considered and rejected the request, according to the Senate report. 

In a 10 a.m. phone call on Feb. 8, Wingate pleaded with a Blue Cross Blue Shield of Delaware representative to reconsider. 

"This guy needs a stress test or he's going to drop dead," Wingate said, according to phone records provided by Fields. 

Fields' condition had worsened and he could not climb stairs or shovel snow without fighting for breath and suffering from chest pressure he described as feeling like a balloon was inflating inside his chest. 

"We've been trying to appeal this and, and I feel myself getting weaker," Fields told an insurance company representative named Kathy, also on Feb. 8. 

Fields, who has hired a lawyer and is considering legal action, said he had become "desperate" and even began "begging" Blue Cross Blue Shield of Delaware to foot the bill for his tests. He requested the phone records recently from BCBSD. 

Later, Fields requested the home address of a doctor denying his request. "That way, I can send a picture of my 9-year-old son to them so he can understand who needs to be taken care of when I fall over dead with a heart attack." 

On Feb. 9, Fields underwent a cardiac catheterization at Christiana Hospital, during which Dr. Andrew Doorey, of Cardiology Consultants in Newark, threaded a catheter into the blood vessels leading to Fields' heart, discovering "critical coronary artery disease," according to a letter that Doorey sent to Stewart on March 5. Doctors performed quadruple bypass surgery on Feb. 10.

In his letter, Doorey wrote that Fields was "visibly shaking" after learning he required immediate bypass surgery. 

"He was shaking because he realized how close to death he had come due to the repeated refusal of Blue Cross and MedSolutions to allow him to have a stress tests," Doorey wrote. 

SUGGESTED ACTIONS

The Department of Insurance's recommendations for Blue Cross Blue Shield of Delaware:
1. Eliminate guaranteed savings clause in MedSolutions contract.
2. Do not use pre-authorization criteria more restrictive than those published by professional organizations, such as the American College of Cardiology.
3. Ensure denials are being conducted by health care personnel with expertise in field of medicine being reviewed.
4. Clean up claim handling and complaint reviews.