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Insurer’s Contract To Trim Scans Called Illegal

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It seems that Blue Cross Blue Shield of Delaware (BCBSD) hired a company that guaranteed it could save the insurer 20 percent on cardiac nuclear imaging exams and other high-tech scans.

Well, there’s only one way the contractor could do that, right? Disallow payment for as many such tests as possible.

An investigation by Delaware’s Department of Insurance found that the contractor denied payment too often. Further, the department says, the contract violated state law.

Here’s the story, according to The News Journal, a newspaper in New Castle County, Delaware: In July 2009, BCBSD contracted with MedSolutions, a medical cost management company from Franklin, Tennessee, to review claims before doctors were allowed to administer high-tech scans, including knee MRI and CT brain scans.

The contract contained financial penalties if MedSolutions didn’t reach a target of 20 percent savings. That provision, according to the Department of Insurance, violated state law.

The department’s report also criticized BCBSD and MedSolutions for denying 24 percent of requests to pay for nuclear stress tests.

The department hired Marc Tecce, MD, a cardiologist at Thomas Jefferson University in Philadelphia, to review BCBSD records. Dr. Tecce said MedSolutions’ standards for approving nuclear stress tests were stricter than those of the American College of Cardiology (ACC), the American Heart Association, and the American College of Radiology—and were not appropriate for high-risk patients.

BCBSD issued a statement saying that in March 2010 it reviewed its preauthorization protocols for high-tech imaging and made several changes easing restrictions.

The savings guarantee was deleted from the MedSolutions contract last summer, during the investigation.

MedSolutions is unrepentant. A statement on its Web site says a 2009 study by the ACC itself found that as many as 29 percent of nuclear stress tests either were found to be inappropriate or could not be definitively determined to be appropriate. “MedSolutions helps ensure that unnecessary, expensive, and potentially harmful testing is avoided,” the statement says.

It also said that the ACC guidelines were flawed and that “61 percent of the physicians involved in the creation of the ACC’s nuclear cardiac guidelines reported a conflict of interest.”

Related seminar: Cardiac Imaging


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One Response to “Insurer’s Contract To Trim Scans Called Illegal”

  1. Radiology Daily»AlertArchive » Blue Cross Reignites Prior-Authorization Battle on October 7th, 2011 at 10:03 am

    […] Cross Blue Shield of Delaware (BCBSD) got in trouble last year when a claims administrator that it hired, MedSolutions of Franklin, Tennessee, denied 24 percent […]