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Delaware Blues illegally denied high-tech tests, regulator says

Findings by the state's insurance commissioner and a Senate panel prompt calls for health plans to stop using third-party utilization managers.

By Emily Berry — Posted May 4, 2011

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Some Delaware physicians say findings that the state's Blues plan illegally denied some high-tech cardiac imaging tests are evidence that requiring preauthorizations for tests delays or blocks necessary care and creates excess paperwork for doctors.

A congressional panel and state regulators concluded that Blue Cross Blue Shield of Delaware contracted with a utilization management firm for nearly a year under terms that gave the vendor a financial incentive to deny care. That provision violated state law, according to the state's insurance commissioner.

The two reports outlined the way the company used flawed guidelines to deny coverage for high-tech cardiac imaging tests. One of the reports was prepared April 6 for Delaware Insurance Commissioner Karen Weldin Stewart. The other was written April 15 for U.S. Sen. Jay Rockefeller (D, W.Va.). Both reports noted that physicians overuse high-tech imaging and were critical of incentives for doctors to order unnecessary tests.

Eleven months into its arrangement, the Delaware Blues eliminated the financial incentive in its contract with Franklin, Tenn.-based utilization management firm MedSolutions, and stopped requiring preauthorization for nuclear cardiac stress tests.

"The health and safety of our members are vitally important to us," the Blues said in a statement in response to the two reports. "We implemented our high-tech imaging preauthorization 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."

MedSolutions said in a statement: "By helping physicians adhere to evidence-based guidelines, MedSolutions offers a service that improves the quality of care while generating cost savings by reducing unnecessary, inappropriate and less safe tests. ... At no point -- ever -- are any criteria considered that do not put the quality and safety of patient care first."

Weldin Stewart did not say if her department would fine the Blues plan in connection with her department's findings.

Some physicians said they hope state and federal officials see the case as a sign that third-party utilization management companies are not the answer to controlling costs while encouraging quality care.

"I think what happened in Delaware is a microcosm of where we're headed in medicine," said David Bercaw, MD, a Wilmington, Del., family physician and president of the Medical Society of Delaware. "The cost of medicine is kind of running away from us. What's happened here is an attempt to gain control of some of those costs. However, it didn't make sense in the way it was done."

Wilmington cardiologist Gaetano Pastore, MD, immediate past president of the Delaware chapter of the American College of Cardiology, said insurers should use a single, evidence-based set of standards to approve diagnostic tests, one developed by specialists in a given field. (See correction)

"As long as we have insurance companies, they're going to be involved in the process, but insurance companies should not be involved in deciding what criteria are used," he said.

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