Insurer denied needed medical tests, Senate finds

Insurer denied needed medical tests, Senate finds
In 10 to 15 percent of cases, crucial heart test was rejected by firm hired to screen requests
By Lisa Myers, Rich Gardella and Azriel Relph
NBC News
2011-04-16

“I gotta tell you Kathy, I can’t keep living like this,” said Michael Fields, 46, who was experiencing tightness in his chest, numbness in an arm and light-headedness as he begged the voice at the other end of the line for help. “It’s been going on for weeks. I don’t know what else to do. I mean you know, I’m trapped here.”

“Alright, let me put you back on hold,” came the reply.

Fields, who lives with his wife and son in Elkton, Md., was not speaking with a 911 operator. He was calling a representative from his insurance provider, Blue Cross/ Blue Shield of Delaware, and he was about to find out that for the third time he was being denied a crucial test to determine if he had coronary artery disease — a nuclear cardiac stress test.

A Senate investigation released Friday found a pattern of inappropriate denials for tests like the one Fields’ doctors say he should have received from the start.

The investigation looked at 1,600 cases over a six-month period from 2009 to 2010 involving requests for nuclear cardiac stress tests in the state of Delaware. All of the cases studied were handled by MedSolutions, a company that screens test requests in the state for Blue Cross/Blue Shield of Delaware and other insurers.

According to the report, “10 to 15 (percent) of requested tests appear to have been denied inappropriately. MedSolutions and the Delaware insurers denied a significant number of medically necessary nuclear stress tests.”

“It is a huge number,” Sen. John D. Rockefeller, chairman of the Senate Commerce Committee told NBC News. “I don't care if it is 5 to 2 percent, it is a huge percent. It follows a pattern that never stops with health insurance companies. It is always the bottom line. The more they say no, the more money they make.”
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Michael Fields was one of those found to have been wrongly denied.

Request for test denied repeatedly
When Fields first complained about his symptoms over a year ago, his physician sent him to get a stress test. The request was denied by Blue Cross Blue Shield, and denied again after two appeals by the physician. Finally, his doctor sent him to the hospital, where cardiologists found that a key blood vessel to his heart was almost completely blocked.
Phone calls edited to remove personal info, holds

The next day Fields had an emergency quadruple heart bypass.

“This is as serious as you can get,” said Dr. Andrew Doorey, the cardiologist who saw Fields at the hospital. “There’s no second chance with this.”

When Doorey learned that Fields had been repeatedly denied a stress test by Blue Cross/Blue Shield and MedSolutions, he fired off a complaint to the Delaware Insurance Commission.

Coronary artery disease occurs when arteries supplying oxygen-rich blood to the heart become blocked. It causes one out of every six adult deaths in the United States, according to the American Heart Association. Nuclear stress tests are a way of taking a three-dimensional picture of the heart and diagnosing the disease. Radioactive “tracers” are injected into the bloodstream and an X-ray camera takes multiple pictures of the heart from different angles.

Experts say the nuclear stress tests have a diagnostic accuracy in the 90 percent range. A basic stress test, in which a patient exercises on a treadmill while connected to electrocardiogram (or ECG) equipment, is accurate 70 percent of the time. According to data from the American Medical Association, nuclear stress tests can cost up to five times as much as an ECG test.

Concerns over increasing costs
Over the past decade, there have been concerns about the rapidly increasing cost of imaging tests, as well as accusations that physicians — some of whom own and operate the expensive equipment used — were overutilizing the tests.

In response, in 2005 the American College of Cardiology published guidelines for the appropriate use of nuclear stress tests. In 2009 after one in five heart scans performed were found to be unnecessary, those guidelines were updated. Meanwhile, insurers began using third-party “radiation benefit management” companies, like MedSolutions, to conduct prior authorization reviews of test requests.

MedSolutions claims on its website that it can deliver insurers savings of 25 to 30 percent, stating that it “rewards the clinically accurate providers while protecting patients from unnecessary utilization and associated risks.” But, according to a report from the Delaware Insurance Commission, the company had a financial incentive to deny tests. The report says a provision of MedSolutions’ contract with Blue Cross Blue Shield of Delaware required it to return 10 percent of its administrative fee if the annual costs associated with the services it managed did not fall by 20 percent.

According to Delaware law, it is illegal for an administrator’s fees to be “contingent upon savings effected in the adjustment, settlement and payment of losses covered by the insurer’s obligations.” MedSolutions and Blue Cross Blue Shield say they dropped the provision last year — after the investigation had begun and before any annual cost savings had been calculated.

Karen Weldin Stewart, Delaware’s Insurance Commissioner, was mildly critical of Blue Cross Blue Shield’s overall handling of nuclear stress tests. She complained that, in some cases, tests were denied by medical personnel not fully qualified to make the decision. She said that the company used guidelines less likely to result in approval of the tests than those adopted by the American College of Cardiologists.
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Insurer asked to change guidelines
“Overall, we did not find a lot of problems,” said Stewart. “What troubled us most was that the criteria they were using was more stringent than the American College of Cardiologists uses.” The state is asking Blue Cross to change to the less restrictive guidelines.

In the ACC guidelines, patients with intermediate and high risk to coronary artery disease should be considered for a nuclear stress test. But according to MedSolutions’ guidelines, even a high-risk patient — like Michael Fields, who was a diabetic and a smoker with a family history of heart disease — must first take the cheaper and less accurate ECG treadmill test.

“A stress test, had it been carried out when it was first ordered almost a month earlier, would have definitely picked this up,” said Doorey. “This is someone who was a perfect candidate by broad consensus and the only reason to deny him would be to cut your expenses.”

Neither MedSolutions or Blue Cross Blue Shield would comment on Fields’ case, citing privacy laws.

In a statement to NBC News, MedSolutions' chief medical officer, Dr. Gregg Allen, disputed the Senate's findings and argued that cardiologists overuse these tests, often because they have a financial interest.

MedSolutions has developed guidelines to "ensure that patients receive the right tests at the right time," it said. "At no point, ever, is any criteria considered that doesn’t put quality and safety patient care first."

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Blue Cross/Blue Shield of Delaware said in a statement that it has since changed its procedures, provided staff with additional education, and no longer requires pre-approval of nuclear stress tests. (Manufacturers of machines for these tests include Phillips, Siemens and General Electric — a part owner of NBC Universal, a partner with Microsoft in msnbc.com.)

Michael Fields still has not gotten over the desperation he felt last year. He considers himself lucky to be alive and treasures time with his son even more.

“They're playing God,” Fields said of his insurance company and its subcontractor. “I'm probably cheaper dead than alive to them.”

He pointed to a picture of his 10-year-old son: “I almost left him without a father. It’s crazy.”