MedSolutions says it uses evidence-based guidelines from nationally recognized scientific literature.

"Our company follows these clinical guidelines exactly with the information that is presented to us by the patients' doctors," said Gregg Allen, MedSolutions chief medical officer, in a statement e-mailed to DOTmed News.


When it comes down to the financial issue, the company-connected source says patient care comes first, but recently, there has been an issue with over-testing, posing an expense to the health care system and a risk to patients with regard to radiation exposure.

"We might recommend a more expensive test if it's appropriate," the source says. "There is an expense associated with over-testing, and it's an unnecessary expense added to the health care system."

MedSolutions also has a peer-review system in which physicians can appeal their denials and learn more about why their test was denied coverage and where they can go from there.

One of the reasons Aetna turns to a company like MedSolutions is to make sure the tests are being ordered and administered appropriately.

"There's very significant regional variation in how these tests are used," says Aetna spokesman Walt Cherniak. "We contract with a firm like MedSolutions to monitor this."

Some argue that insurance companies deny coverage because it will save them money, while insurance companies say doctors receive a payout for ordering these tests, which might be an incentive to order them.

"Certain doctors immediately go right to the [nuclear medicine] test, the most extensive, the most expensive test, and they're just ordering it all the time," he says. "So you say, 'all right, why is this doctor doing this?' And in the majority of those cases, those doctors own that testing machine. He bought it and has got to pay for it, and there's a profit to be made once it's paid for. There are a lot of things going on here."

But the ACC's Murphy says, "All of the decisions [to order tests] are based on clinical evidence. Our number-one concern is the patient and making sure the patient gets the appropriate and best treatment."

The hearing is scheduled for 1 p.m. on April 14 in Legislative Hall in Dover.

Read The News Journal coverage at www.delawareonline.com.

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