North Carolina physicians oppose preauthorization for echocardiograms

The state's Blues plan estimates that as many as 15% of the heart tests are unnecessary.

By Emily Berry — Posted March 14, 2012

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North Carolina physicians with multiple organized medical groups have asked the state's Blues plan to reverse course and eliminate a new administrative approval process for physicians ordering echocardiograms.

As of mid-January, Blue Cross and Blue Shield of North Carolina requires preapproval before it will pay for stress echocardiography, transesophageal echocardiography and resting transthoracic echocardiography. The tests are used to diagnose heart defects and disease.

The echo exams were among 13 added to a list of tests for which the North Carolina Blues requires preapproval. American Imaging Management, a subsidiary of WellPoint, handles the approval process. Although WellPoint owns for-profit Blues plans, it does not own the nonprofit North Carolina Blues.

Before the policy took effect, the Medical Society of North Carolina, the North Carolina Hospital Assn. and the North Carolina chapters of the American College of Cardiology and American College of Radiology sent a co-signed letter to Blues CEO Brad Wilson, asking him to eliminate the requirement.

"This policy will impose a substantial hardship on both patients and physicians, with little benefit to BCBSNC and its subscribers," the letter stated. "Requiring a physician to go through a prior approval process for a basic and routine test for heart disease is incredibly burdensome for the physician and will force many patients to make a second office visit for a test that could have been performed at the first visit absent the prior approval process."

The letter mentions that Blue Cross Blue Shield of Delaware was fined $325,000 in October 2011 after the state's insurance commissioner concluded that the insurer improperly had denied nuclear cardiac imaging tests. The Delaware Blues denied breaking state law but agreed to change its policy to follow ACC guidelines when considering whether a test is necessary.

North Carolina Blues spokesman Lew Borman said the plan's new policy was implemented after extensive discussion with its panel of medical advisers, and that there had been few complaints from physicians. He noted that the prior approval requirement does not apply to emergency situations.

Cardiac echocardiograms cost the company about $17.5 million a year, and as many as 15% of the tests are unnecessary, he said.

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