The News Journal

Insurer Probe Nearly Finished

By JONATHAN STARKEY • The News Journal • October 28, 2010

Investigators will report to state Insurance Commissioner Karen Weldin Stewart by the end of the month on whether three Delaware health insurance companies inappropriately denied coverage for tests designed to diagnose heart problems, Stewart said this week.

Stewart launched the "market conduct examinations" in March after a series of articles in The News Journal suggested that Blue Cross Blue Shield of Delaware and others were putting patients at risk by refusing to pay for the advanced imaging tests.

The results were originally due this past summer, but Stewart said her office "had a difficult time finding qualified people to go through the files."

At least one cardiologist from Thomas Jefferson University Hospital in Philadelphia has combed through each of the insurance carriers' files, Stewart said.

Insurers here require that doctors obtain permission before performing certain diagnostic procedures, and several use a third-party claims administrator, MedSolutions, of Tennessee, to review requests.

A publicly available report won't be issued until at least January or February, Stewart said, giving the insurance companies time to contest any findings.  The companies involved in the investigation are BCBSD, Aetna and Coventry Health Care.

"If it happens to you, if you get a denial, it's a big deal," said state Rep. Danny Short, R-Seaford. "It's something that can create much stress in your life."

Short introduced legislation this year designed to punish insurance companies for inappropriately refusing coverage for important diagnostic tests.  He tabled that legislation to allow time for Stewart's office to complete its investigation.

Short visited Stewart's offices late last month to be briefed on the investigation, but Stewart required him to sign a confidentiality agreement, so he could not discuss details of the meeting.

The denials controversy began early this spring when doctors and patients came forward to complain that denied coverage was limiting patients' access to important diagnostic procedures.

A Maryland man, Michael Fields, was denied coverage for a nuclear stress test three times before doctors found severe arterial blockage threatening to cause a massive heart attack. The nuclear procedure uses a radioactive tracing material and advanced cameras to identify blockages.

The insurance companies and MedSolutions have said pre-authorization programs limit unnecessary testing, which they said can be harmful and costly.

BCBSD and Coventry did not respond to calls Wednesday seeking comment.

An Aetna spokesman said the carrier re-implemented pre-authorization requirements last month, and even expanded requirements. He also said Aetna is cooperating with investigators.

Delaware cardiologists say they have met with representatives from BCBSD to discuss alternatives to a cardiac pre-authorization program.

"We're trying to work together to come up with a solution," said Dr. Gaetano Pastore, a cardiologist who leads the Delaware chapter of the American College of Cardiology, which publishes criteria detailing when it's appropriate for doctors to order certain tests.