The News Journal

By JONATHAN STARKEY • The News Journal • September 14, 2011

Delaware Insurance Commissioner Karen Weldin Stewart on Tuesday ordered Blue Cross Blue Shield of Delaware to pay a $325,000 fine for problems in how the company approved and paid for cardiac testing ordered by doctors.

Blue Cross, which refused to pay for testing ordered by cardiologists and primary-care physicians , also will work with the American College of Cardiology on a pilot program designed to reduce inappropriate testing. The tests in question are high-tech nuclear-imaging tests used to diagnose artery blockages that cause heart attacks. Blue Cross and the Insurance Department agreed on the program and fines in settlement negotiations.

A series of stories in The News Journal last year revealed that Blue Cross, the state's largest health insurer, was denying patients access to needed tests through a third-party claims administrator -- MedSolutions, of Franklin, Tenn.

Blue Cross used MedSolutions to prescreen requests by doctors for nuclear cardiac exams and other high-tech tests. The use of such imaging tests has boomed in recent years, and insurers across the country have turned to so-called benefits managers to rein in the ordering of unnecessary tests.

Stewart and the Commerce Committee of the U.S. Senate launched probes into the matter after the stories were published. Stewart said her office's agreement with Blue Cross "is another step on solving the complex problems of delivering the highest quality care to Delaware citizens."

Blue Cross' contract with MedSolutions included guaranteed savings targets that were tied to the company's compensation. That violated provisions in state insurance code, according to Stewart's findings, which were published in April. That report also noted that Blue Cross denials made it difficult for patients to access necessary care and pointed out six cases in which patients were treated for an emergency heart ailment after a denial.

One patient profiled in the newspaper's stories had to be admitted through an emergency room for a heart bypass operation within weeks of a Blue Cross denial of his doctor's request for a cardiac stress test that should have revealed his arterial blockage.

Blue Cross has eliminated its pre-authorization program for nuclear stress testing. In a statement, Blue Cross said that "as part of our ongoing efforts to enhance and refine our guidelines to benefit our members, we continue to consult with cardiologists concerning cardiac testing and treatment."

The insurer agreed to enter a program run by the American College of Cardiology, which develops cardiac testing criteria. Doctors will use a computer program to determine whether tests they plan to order for patients are appropriate based on a patient's set of symptoms and medical history.

Blue Cross will underwrite the three-year program at a cost of $100,000 a year, Stewart said. Delaware doctors are to begin using the program, called FOCUS, this fall.

Patients and physicians participating in the pilot program will not be denied any testing. It's intended as an alternative to benefits managers and should reduce inappropriate testing over time by giving doctors feedback about why a test was termed "inappropriate," said Dr. Janet Wright, senior vice president of science and quality for the American College of Cardiology. The program also allows doctors to map their own testing patterns.

"They can not only see their pattern but they can compare themselves to other practitioners," Wright said. "They don't like to be out of line with their compatriots. Just having that feedback shapes behavior like nothing else."

Data, including some published in the Journal of the American College of Cardiology, show that doctors often do order tests inappropriately. One multi-location study last year showed that more than 14 percent of nuclear stress tests were wrongly ordered and those percentages are higher among primary-care physicians, who often refer patients to specialists.

The cardiology program should generate a wealth of Delaware-specific data about the appropriateness of testing.

"You will see that the majority of physicians are doing what's appropriate," said Gaetano Pastore, a Newark cardiologist and immediate past head of the Delaware chapter of the American College of Cardiology.

Fines paid by Blue Cross will be directed to the state's General Fund, an idea that was questioned Tuesday by state Rep. Daniel B. Short, a Seaford Republican.

Short, who has introduced legislation designed to punish insurance companies for wrongly denying tests, said the tests should be used to lower health insurance premiums or to expand the cardiology program to include other insurance companies. Generally, Short praised Tuesday's announcement.

"For me, this has always been about ensuring that Blue Cross Blue Shield customers can trust that they are receiving the best quality care, regardless of costs," Short said. "I am confident today's consent order will be a step in the right direction in helping to save lives."