BlueCross BlueShield of Delaware (BCBSD) is under fire from several lawmakers after it put forth new criteria that will require imaging scans, such as CT and MRI, to be pre-approved by a third-party company MedSolutions, which will determine whether or not the test is “appropriate” for a patient.

According to a March 25 press release from BCBSD, MedSolutions, a company that reviews medical testing, has been employed and has been pre-authorized to review imaging tests for patients since July 2009. The payor said that it began requiring pre-approval in an attempt to contain mounting medical costs. BCBSD outlined the changes to insurer’s plans that will take effect July 1.

In the document, BCBSD said that “failure to receive approval prior to having the test performed will result in the claim being denied and the provider is held accountable for the entire cost of the test.”

In addition, the company wrote that “tests and scans performed during a member’s hospitalization or emergency room visit are exempt from this program. The member is responsible for applicable out-of-pocket expenses.”

According to a report by the Wilmington, Del.-based News Journal, the pre-authorization guidelines will affect almost 100,000 Delaware state workers, their spouses, children and retirees.

On April 14, Delaware Insurance Commissioner Karen Weldin Stewart held a meeting with legislators to discuss the pre-approval process of cardiac CT angiography, CT, MRI, PET and nuclear imaging tests by MedSolutions.

The meeting was called by Stewart after state media scrutinized the commissioner’s office for not responding to a physician’s letter, received March 10, that informed “the department that the pre-authorization process resulted in a denial of service,” and requested an investigation of BCBSD and its policies.

“Our response to the initial and only complaint in two years made to the department in connection with these denials from any source including doctors, patients, legislators and other health care agencies, a complaint made well after the patient had completed his surgery, was immediate,” Stewart said. “Our subsequent meeting with BlueCross BlueShield of Delaware produced a suspension of all denials of services and was provided to a major Delaware media outlet, prior to any federal inquiry, on the condition that it not be made public.”

Additionally, on March 25, Sen. John D. Rockefeller, D-W.Va., chair of the Senate's Commerce, Science and Transportation Committee, sent a letter to Timothy Constantine, CEO of BCBSD, after the media had reported that the company “repeatedly denied requests from both primary care physicians and cardiologists to pay for cardiac stress tests that the doctors have determined are medically necessary.”

Rockefeller and the senate committee at that time launched a full-fledged investigation of BCBSD, requiring them to fork over information to the committee pertaining to the process for determining when a cardiac imaging test is necessary.

The information sought included: identifying those responsible for making the decision, how the process is communicated to policyholders and physicians, a policyholder's rights to appeal the decision and how BCBSD communicates with its policyholders and physicians about the right to appeal.

On April 16, Rockefeller extended his investigation, and sent letters to the CEO’s of Coventry Health Care and Aetna requesting the same information about their policies on the pre-authorization of imaging test coverage.

“The requests follow recent news reports in the Delaware News Journal that insurers in Delaware have refused to approve these tests for their patients,” Rockefeller wrote.

“I intend to keep a close watch on the health insurance industry, and to ask the tough questions about how they do business – especially now that we have passed a landmark healthcare reform bill,” he said. “Denying medically necessary services to patients showing a sign of serious heart disease is not tolerable. I will continue to fight to make sure Americans are getting the health care they have paid for and deserve.”

In addition to the current investigation by the transportation committee, Stewart began conducting a market investigation March 27 of the pre-authorization process for Aetna, Coventry Health Care and BCBSD.

At that time, BCBSD said that it had “asked MedSolutions to suspend the issuance of any denials.” In addition, the company said that it “continually reviews services performed by external parties or vendors and we are currently reviewing our high-tech radiology pre-authorization program.”

“For my department to successfully serve Delaware’s citizens, they and their physicians must promptly notify us of the difficulties they are encountering getting their tests covered, their claims paid, and with any other issues that we have the authority to address,” Stewart concluded.