Delaware Blues fined for denying cardiac tests

Delaware's insurance commissioner has fined the state's Blues plan $325,000 over what the commissioner deemed inappropriate denials of nuclear cardiac imaging tests.

Blue Cross Blue Shield of Delaware "acknowledged deficiencies in claims handling" but denied violating state law. It agreed to pay the fine and spend an additional $300,000 over three years on a program developed by the American College of Cardiology to guide the appropriate use of advanced cardiac imaging tests.

The news was welcomed by the ACC, which credited its Delaware chapter with helping to broker the agreement.

"We hope Delaware will be a model for managing medical costs by focusing on patient-centered decision making and quality care," ACC Chief Executive Officer Jack Lewin, MD, said in a statement. "More importantly, we hope this proactive solution will prevent future cardiovascular patients from being denied the right care at the right time."

The ACC program, called FOCUS, for Formation of Optimal Cardiovascular Utilization Strategies, is a patient information database designed to help physicians develop and adhere to best practices for use in high-tech imaging. Physicians will enter patient information into the FOCUS database and will not have to request preapproval to be paid for a test.

Insurance Commissioner Karen Weldin Stewart released a market conduct report in April that found the company's arrangement with Franklin, Tenn.-based MedSolutions violated state law because it included a financial incentive for MedSolutions to deny tests.

Amid the investigation, the Blues plan ended its work with MedSolutions in March 2010 and stopped requiring preauthorizations for the tests in question.

The office of U.S. Sen. Jay Rockefeller (D, W.Va.), chair of the Senate Committee on Commerce, Science and Transportation, also investigated the denials and found that they interfered with appropriate care. His office released a statement praising the action against the Delaware Blues.

"This new approach puts the focus on appropriate patient care instead of maximizing profits," Rockefeller said in a statement.