Delaware Blues wrongly denied vital imaging tests

Blue Cross Blue Shield of Delaware violated state law by signing a contract with MedSolutions that guaranteed the insurer would save money by denying high-tech imaging tests, such as nuclear cardiac exams, the Delaware News Journal reports.

In July 2009, BCBSD instituted a pre-authorization requirement for high-tech imaging, hiring MedSolutions to apply its own criteria for the determination of reimbursable exams. As part of the contract, BCBSD required MedSolutions to refund 10 percent of its fee if it didn't save the insurer 20 percent or more on radiology payments, according to CMIO. Delaware's Department of Insurance found that this provision violated state law because the charges are contingent upon savings to the insurer.

A parallel probe conducted by the federal government has reached a similar conclusion after reviewing 1,600 cases over a six-month period from 2009 to 2010 involving requests for nuclear cardiac stress tests in Delaware. In all cases, MedSolutions screened test requests for BCBSD and other insurers resulting in the inappropriate denial of 10 to 15 percent of requested tests, NBC News reports.

According to the federal report, Blue Cross inappropriately denied 33 physician orders for cardiac nuclear imaging studies, amounting to 12 percent of its total denials for the exams between July 2009 and June 2010. Another 43 were denied for administrative purposes, such as insufficient information or a scan ordered without a doctor having seen the patient in more than 30 days, notes the DNJ.

The Delaware insurance department also determined that, in some cases, tests were denied by medical personnel not fully qualified to make the decision. So it is now recommending BCBSD employ cardiologists to authorize or deny cardiac imaging exams. But BCBSD says other providers have sufficient expertise and called the recommendation "factually incorrect," notes CMIO.

Delaware Insurance Commissioner Karen Weldin Stewart likely will assess a fine or impose other penalties because of the illegal contract clause, the DNJ notes.

To learn more:
- read the Delaware News Journal story
- check out the CMIO article
- see the NBC News piece

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