Insurer Wrongly Denied Vital Imaging Tests

Blue Cross Blue Shield of Delaware (BCBSD) has reportedly violated state law by signing a contract with Franklin, Tenn.-based radiology benefits management company 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, at which point it hired MedSolutions to apply its own criteria for the determination of reimbursable exams. Under terms of the contract, MedSolutions was required by BCBSD to refund 10% of its fee if it didn't save the insurer 20% percent or more on radiology payments. Delaware's Department of Insurance found that this provision violated state law based on the fact that the charges are contingent upon savings to the insurer. Meanwhile, a similar conclusion has emerged from a parallel probe conducted by the federal government; the latter entailed a review of 1,600 cases over a six-month period from 2009 to 2010 and involved 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% 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% of its total denials for the exams between July 2009 and June 2010. Another 43 tests 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. Moreover, the Delaware Insurance Department determined that, in some cases, tests had been denied by medical personnel who were not fully qualified to make the decision. Consequently, it is recommending that BCBSD employ cardiologists to authorize or deny cardiac imaging exams. However, BCBSD says other providers have sufficient expertise and considers the recommendation factually incorrect. Delaware Insurance Commissioner Karen Weldin Stewart likely will assess a fine or impose other penalties because of the illegal contract clause, the DNJ notes.