Imaging lobby slams Blue Cross pre-authorization proposal

October 06, 2011
by Diana Bradley, Staff Writer
On Wednesday, the Medical Imaging & Technology Alliance, a medical equipment lobby, called on Congress to reject the Blue Cross Blue Shield Association’s proposal for Medicare to use preauthorization for advanced imaging services.

According to the BCBSA's document, "Building Tomorrow’s Healthcare System: The Pathway to High-Quality, Affordable Care in America," U.S. health care spending exceeds $2.5 trillion annually and 30 cents of every health care dollar feeds ineffective, redundant care.

In an effort to cut costs, the association has proposed a preauthorization program to ensure appropriate outpatient diagnostic imaging utilization, evidence-based clinical criteria and pertinent exchange of member information.

The insurance group claims a similar program it has run since 2006 realized a gross return on investment of over 10 to one in its first two years. But MITA fears BCBSA's newly proposed procedure, also submitted to the Department of Health and Human Services, will deny physicians and patients the ability to make medical decisions -– leaving the insurance industry in charge.

"A proposal by an association of the health insurance industry to put medical decisions in the hands of the health insurance industry is simply a means to reduce access to medical imaging," David Fisher, executive director of MITA, said in a statement.

Recently, 63 percent of 2,400 American Medical Association physician survey respondents agreed prior authorization delays needed medical procedures. No peer-reviewed health economic research currently exists to prove prior authorization produces savings for Medicare, MITA said.

In addition, MITA observed that HHS noted back in 2008 that such a program would be “inconsistent with the public nature of the Medicare program,” since physician-prescribed care would be denied by private companies’ utilization of propriety systems.

"We know that these programs are highly burdensome and reduce access to care,” said Fisher.

In April, Blue Cross Blue Shield of Delaware (BCBSD) faced a backlash for its preauthorization program, when the state’s Department of Insurance discovered they were denying patients what may have been medically necessary diagnostic cardiac stress tests.

Delaware’s insurance commissioner and the U.S. Senate Committee on Commerce, Science and Transportation’s investigations found BCBSD had violated state law by signing a contract with MedSolutions, a company that denied nearly 30 percent of requests to cover nuclear stress tests, lessening costs.

The Senate’s investigation report found the preauthorization procedure negatively affected patient Michael Fields and “unnecessarily delayed care for his life-threatening medical condition.” Doctors sent in a number of similar complaints from other patients regarding the stress tests.

In the end, the evidence prompted BCBSD to modify its policies so that doctors no longer needed preauthorization. BCBSD will now enter into a new pilot program with the American College of Cardiology that will automatically approve tests for patients of physicians who utilize the new program. Last month, BCBSD was also fined $325,000 by the state’s Insurance Commissioner Karen Weldin Stewart.

According to Fisher, evidence-based, physician-developed appropriateness criteria should be used by health care providers to ensure patients have access to the correct scan at the right time. The preauthorization process is a major source of controversy as the clinical criteria insurers and their venders use for approval differ from the criteria ordering physicians follow, MITA said.

Fisher noted: “Policymakers should not place additional hurdles between patients and necessary diagnostic and screening services.”