The News Journal

Delaware health: Insurer to drop approval directive

By JONATHAN STARKEY • The News Journal • June 17, 2010

Blue Cross Blue Shield of Delaware, the state's largest private health insurer, will stop requiring doctors to obtain permission before performing nuclear stress tests, according to Elliott Jacobson, chief of staff for state Insurance Commissioner Karen Weldin Stewart.

The tests -- which use a radioactive tracing material and advanced imaging machines to detect artery blockages that can cause heart attacks -- are at the center of a Delaware controversy over whether health insurers should second-guess doctors.

David Ramos, a Dover cardiologist, called Blue Cross' decision to stop denying coverage for nuclear stress tests "promising news."

"Less interference in the practice of medicine I always favor," Ramos said.

Jacobson said it's "the responsible thing to do."

Blue Cross would not comment on proposed changes to its pre-authorization program, though it is expected to announce a set of changes soon. The carrier has been considering changes since March, when it was accused of endangering patients' health by refusing to pay for diagnostic exams that doctors believed were necessary to properly diagnose and treat patients.

Pre-authorization requirements, common among private insurers looking to hold down costs, force doctors to prove that a procedure is necessary before performing that test. Insurance companies often disagree with doctors on what's needed -- and what's not.

Blue Cross and Aetna contract with a Tennessee company, MedSolutions, to run their pre-authorization programs for high-tech imaging exams performed in outpatient settings, including nuclear stress tests, MRIs, and CT and PET scans.

After stories in The News Journal suggested that MedSolutions was inappropriately denying coverage in Delaware, Stewart and a U.S. Senate committee opened investigations into the pre-authorization practices at Blue Cross, Aetna and Coventry Health Care. Those investigations are still under way.

At Stewart's request, the carriers placed a moratorium on stress test denials, giving her office a chance to complete its review. Aetna will lift its moratorium on July 14. Meanwhile, Aetna has continued to push forward with pre-authorization requirements for other imaging exams, including MRIs and CT scans. Blue Cross halted denials across its advanced imaging pre-authorization program.

Coventry has refused to return calls or answer questions about the investigations.

Repeatedly, MedSolutions has defended its denials in Delaware, even in the case of Michael Fields, an Elkton, Md., man who was denied coverage three times for a nuclear stress test before doctors identified severe artery blockages threatening his life. The company also defends the practice of pre-authorization broadly. MedSolutions says that pre-authorization is needed to weed out unnecessary tests that are costly and in some cases dangerous, because they subject patients to avoidable doses of radiation.

The use of advanced imaging exams has skyrocketed over the last decade, and MedSolutions also worries that some doctors, those who own testing equipment, order tests because they'll gain financially -- not because the tests are medically necessary.

MedSolutions is not alone in its suspicions. A 2009 study from the Medicare Payment Advisory Commission found that doctors with nuclear stress-testing equipment in their offices were twice as likely to order the test.

Delaware doctors say they order tests because they're necessary to detect, or to rule out, potentially life-threatening ailments.

Some also admit to ordering tests defensively -- because they're worried they'll be sued should they miss something.

Either way, doctors claim, prior approval requirements obstruct their practices, often keeping them on the phone with an insurance company reviewer when they should be attending to patients.