The reason for her meeting was to have an in-depth discussion regarding the complicated issue of pre-authorization claims and these denials.

"Attention was given to the nuclear stress test, but there's an overall issue with pre-authorization and MedSolutions," said Mitch Crane, director of consumer services for the department of insurance. "We need to look at that, and we are."


Since Fields' case, seven complaints - three relating to stress tests - have been filed with Stewart's office. It wasn't until a pattern was established that the commissioner could take action, said Elliott Jacobson, the commissioner's chief of staff. "Doctors need to send in complaints," he said, in order for the commissioner to take action.

Stewart is now investigating four of Delaware's major insurance companies--Aetna, Blue Cross Blue Shield of Delaware, Coventry Healthcare and Cigna. These companies have contracted third-party company MedSolutions to review pre-authorization claims.

"We'll be looking into MedSolutions because they were contracted," said Jacobson. "But the ultimate responsibility is the [insurance] carrier."

ACC Weighs In

The American College of Cardiology, an organization that provides test appropriateness guidelines, is speaking out against these insurance denials.

"The biggest [problem] is that people making the decisions in Delaware are not physicians," Amy Murphy, spokeswoman for the American College of Cardiology, told DOTmed News recently (see DM 12214). "They're not using our or any physician-produced or developed criteria."

But MedSolutions said it uses 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.

The News Journal reported Thursday that MedSolutions said it denied 14.2 percent of stress tests requests in the second half of 2009 because it deemed the tests medically unnecessary. This rejection rate is in line with a study published last year in the Journal of the American College of Cardiology, which found that 14.4 percent of nuclear stress tests were ordered inappropriately, based on the ACC's guidelines, according to the Journal.

The ongoing investigation will look at all of the companies involved to get to the bottom of the controversy.

"The more you dig, the more complex the issue becomes," said Jacobson.

Those conducting the investigation, which includes all pre-authorization claims, are independent medical professionals hailing from various organizations and sources, said John Tinsley, special deputy for examinations for the department of insurance.

More Industry Headlines