The Delaware Department of Insurance has reported that Blue Cross Blue Shield of Delaware violated state law by inappropriately denying authorization for cardiac nuclear imaging exams, part of the payor’s policy aimed at driving down costs.  

On July 1, 2009, Blue Cross instituted a pre-authorization requirement for high-tech imaging, contracting MedSolutions to apply its own criteria for the determination of reimbursable exams. As part of Blue Cross Blue Shield’s contract with MedSolutions, Blue Cross required the benefits manager to refund 10 percent of its fee if MedSolutions did not save Blue Cross 20 percent or more on radiology payments.

In a report released to the public on Friday, Delaware’s Department of Insurance found that this provision violated state law, which, in part, states, ”An administrator shall not enter into an agreement or understanding with an insurer in which…charges [are] contingent upon savings” to the insurer.

Blue Cross Blue Shield reported that it never disbursed any funds in relation to this part of the contract, which the payor rescinded on June 3, 2010, approximately one year after the provision’s implementation.

According to the government report, Blue Cross inappropriately denied 33 physician orders for cardiac nuclear imaging studies, amounting to 12 percent of the payor’s total denials for the exams between July 2009 and June 2010. The Department of Insurance’s standard for appropriateness was based on the American College of Cardiology Foundation (ACCF’s) appropriate imaging criteria.

The Department of Insurance’s clinical review of MedSolutions' policies and procedures was performed by Marc Tecce, MD, clinical assistant professor of medicine at Thomas Jefferson University School of Medicine in Philadelphia. Important differences existed between the ACCF guidelines and those used by MedSolutions, Tecce said, explaining, “The MedSolutions' guidelines dispense with critical physician judgment in these situations at the expense of appropriate patient care.”

The report recommended that Blue Cross and MedSolutions adopt the ACCF criteria to determine future cardiac nuclear imaging authorizations. In a letter responding to the department’s report, Blue Cross called this recommendation “inappropriate.” Blue Cross argued that the laws of Delaware and other states do not impose specific criteria by which payors must abide, only noting that their guidelines must be based on the evidence in the literature.

“These particular criteria were not designed to be the standard for determining which test may be most appropriate,” Blue Cross argued.

The payor further criticized the Department of Insurance’s recommendation that Blue Cross employ cardiologists to authorize or deny cardiac imaging exams. Blue Cross contended that other providers have sufficient expertise and called the recommendation “factually incorrect.”

Elliott Jacobson, senior advisor to the Commissioner of the Department of Insurance, told Health Imaging News that the examiners were aware of the insurer's response. “If our report were factually incorrect, we would have changed it. We don’t believe there is a factual inaccuracy, which is why we went public with it.”

Jacobson said that the department is conducting additional investigations into the policies of state payors Aetna and Coventry. These reports are investigating Aetna and Coventry’s authorization policies for imaging beyond the scope of cardiac exams, including CT and MRI.

Jacobson indicated that the commissioner will determine what punitive measures the department will take against Blue Cross, which could include fines and other sanctions, once the forthcoming reports are completed.

“The commissioner (Karen Weldin Stewart) doesn’t want to make any decision yet [on penalties] until she has been able to digest not just this report but also the reports on Aetna and Coventry,” Jacobson said.

To view a copy of the “Market Conduct Examination Report on Blue Cross Blue Shield of Delaware, Inc.,” click here.