Commerce Committee Investigation Reveals That Medical Companies Wrongly Deny Patients Critical Tests

April 18, 2011

Feature Image: 2 Oversight&InvestigationsWASHINGTON, D.C.—Chairman John D. (Jay) Rockefeller IV released a report with the findings of a year-long Commerce Committee staff investigation that found a pattern of inappropriate denials for medically necessary advanced imaging tests for Americans suffering from heart disease. Rockefeller started the investigation following news reports in March, 2010 suggesting that Aetna and Blue Cross Blue Shield of Delaware (BCBSD) were denying patients critical nuclear cardiac stress tests.

“Too many Americans who need life-saving tests don’t get them,” Chairman Rockefeller said. “That’s because health insurance companies employ third-party companies to deny tests that are costly and would hurt their bottom line. This practice is putting profits over people—and putting lives at risk. But some doctors are also part of the problem. Our investigation concluded that doctors, judged using their own standards, are clearly still ordering tests when their patients don’t need them.” 

On Friday, Delaware Insurance Commissioner Karen Weldin Stewart released a report on BCBSD’s preauthorization of advanced imaging heart tests. Among other things, the report found that BCBSD violated Delaware law by giving a third-party company, MedSolutions, Inc., a financial incentive to deny doctors’ requests for heart tests.

“I congratulate Commissioner Stewart and her staff for standing up for the consumers of Delaware,” Rockefeller said. “The Commission’s strong oversight efforts on this issue mean that Delaware patients are going to get the health care they pay for and deserve.”

Key Findings of the Commerce Committee Staff Investigation:

  • Aetna and Blue Cross Blue Shield of Delaware, and health insurance companies nationwide, employ third-party companies to run “pre-authorization” programs for advanced imaging tests, including the “nuclear stress test,” a test that helps doctors diagnose coronary artery disease. 
  • In Delaware, Aetna and BCBSD used one of these third-party “radiation benefits management” companies, MedSolutions, to reduce the number of nuclear stress tests they would have to pay for on behalf of their customers. MedSolutions promises on its website that it will reduce nuclear stress test costs for health insurance companies by 25-30 percent. Fees paid to MedSolutions were based in part on how successfully the company reduced the utilization of the tests. 
  • The pre-authorization process employed by the Delaware insurers was confusing and burdensome for doctors and patients. In a number of cases, MedSolutions denied tests not on the basis of medical necessity, but because doctors and patients did not follow administrative requirements.
  • One of the most confusing features of the pre-authorization process employed in Delaware was that MedSolutions used different clinical guidelines than the ones medical professionals used. Some patients who should have received a nuclear stress test under their cardiologists’ professional guidelines did not. The report reconstructs the case of one patient, Michael Fields, who was denied timely, medically necessary care for more than a month because of this conflict. 
  • Evidence from this investigation and other studies makes it clear that cardiologists and other doctors order nuclear stress tests in situations that their own professional guidelines deem inappropriate. An outside expert hired by the Delaware Insurance Commissioner determined that more than one out of every ten nuclear stress tests ordered by Delaware doctors did not comply with the clinical use criteria established by the American College of Cardiology.

Background on the Commerce Committee Investigation: 

In late March 2010, news reports surfaced out of Delaware describing several instances in which MedSolutions denied cardiologists’ requests for nuclear stress tests. Patients were being denied medical care for serious heart conditions. Based on the information reported, Chairman Rockefeller initiated an investigation into insurers’ denials of nuclear stress tests that Delaware doctors felt were medically necessary. 

On March 25, 2010, Rockefeller sent a letter to BCBSD requesting information about the company’s prior authorization procedures, the number of requests for nuclear stress tests it had allowed or denied, and its business relationship with MedSolutions. On April 16, 2010, Chairman Rockefeller expanded his inquiry by sending similar letters to two other insurers operating in Delaware, Aetna and Coventry.

Through responses to these inquiries, Commerce Committee staff learned that BCBSD and Aetna had contracted with MedSolutions for pre-authorization requests for nuclear stress tests, while Coventry did not use a third-party contractor to review requests for the test.