由 Olga Deshchenko
, DOTmed News Reporter | June 24, 2011
From the June 2011 issue of HealthCare Business News magazine
Blue Cross Blue Shield of Delaware caught a lot of heat recently for denying what may have been medically necessary diagnostic cardiac stress tests, prompting investigations by both the state’s insurance commissioner and the U.S. Senate Committee on Commerce, Science and Transportation.
This April, Delaware’s Department of Insurance released its report, which found that BCBSD violated state law by signing a contract with MedSolutions, a company that guaranteed the insurer would slash costs through denials of high-tech imaging tests.
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According to the report, MedSolutions denied nearly 30 percent of the requests to cover nuclear stress tests. The insurer’s preauthorization program also required physicians to prove the tests were necessary before paying for them.
And Avi E. Soffer, CEO of University Nuclear and Diagnostics, says Delaware isn’t the only state with troubling denials of critical diagnostic tests -- it’s happening nationwide.
According to Soffer, many payers use the health care reform’s goal of trimming the “excess” and controlling costs across system to underpay or completely deny coverage for procedures like nuclear stress tests.
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At the same time as the Department of Insurance released its findings, the Senate shared its summary report on preauthorization in Delaware. It pointed the finger at payers and clinicians, scolding them for not putting patients first.
The Senate’s investigation was triggered by a patient named Michael Fields, who was denied nuclear stress tests twice in January of 2010. He was eventually admitted to a hospital and received bypass surgery. The Senate report found that Fields’ preauthorization procedure “unnecessarily delayed care for his life-threatening medical condition.”
Prompted by the investigations, BCBSD said in April it would modify its policies -- doctors no longer need to obtain preauthorization for nuclear stress tests for the members of the insurance plan.
According to Soffer, a diagnostic stress test is one of the most vital tools in the hands of cardiologists. “It is arguably their most important diagnostic [exam] and certainly the number one contributor to the decrease in cardiovascular disease and detection of ischemia,” he says.
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