Insurance preauthorization denials spark inquiries

A state insurance regulator and Sen. Jay Rockefeller are looking into Delaware Blues' utilization programs, following complaints of routine denials of cardiac stress tests.

By Emily Berry — Posted April 15, 2010

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Years of physician complaints about Delaware health plans' utilization management programs have culminated in inquiries from a U.S. senator and the state's insurance commissioner.

Sen. Jay Rockefeller (D, W.Va.) wrote to Blue Cross Blue Shield of Delaware March 25, citing news reports that said the plan, through contracted utilization manager MedSolutions, was routinely denying requests for prior authorization for cardiac stress tests, even in cases where they appeared to be obviously medically necessary.

Rockefeller, who chairs the Senate Committee on Commerce, Science and Transportation, asked the company to give his office its records, including an explanation for every denial of a cardiac diagnostic test in the last five years.

Then on March 27, state Insurance Commissioner Karen Weldin Stewart announced she had formed a task force and was investigating prior authorization denials by the Blues, Coventry Health Care and Aetna, all of which have hired MedSolutions.

In a statement released that day, she said that until her department had completed its work, the Delaware Blues had agreed to eliminate preauthorization requirements for high-tech radiology services.

MedSolutions, based in Franklin, Tenn., markets its utilization management services with the stated goal of helping insurers save money and improving quality of care.

"The well-being of patients always comes first," MedSolutions Executive Vice President and Chief Medical Officer Gregg Allen, MD, said in a statement. "Our process follows evidence-based guidelines derived from nationally recognized scientific literature."

An April 1 statement from the Delaware Blues said the company would cooperate with the state and federal inquiries, and work with physicians to "review our guidelines and process" for preauthorizations.

Nicholas Biasotto, DO, a family physician and president of the Medical Society of Delaware, said the latest controversy over preauthorizations follows many others, beginning years ago when Coventry became the first plan in the state to hire MedSolutions.

The recent cardiac test denials, he said, are "the straw that broke the camel's back."

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