Health Insurers Limit Advanced Scans

Linda Johnson's article shines a light on insurer company efforts to restrict patient access to life-saving medical imaging technologies. Patients should be skeptical of insurers' decisions to pre-authorize some screening as a means of reducing costs, especially if they view fewer medical images as a "success,%u201D without concern for improved patient care.



Medical imaging is integral to many diagnostic and therapeutic guidelines, and it is short-sighted to ignore the data that demonstrates the value of medical imaging to health outcomes and savings. The American Cancer Society's endorsement of virtual colonoscopies as part colon cancer screen guidelines serves as a prime example.



Appropriateness criteria and accreditation are important for ensuring the most suitable and safe use of imaging for patients. While cost is also a necessary consideration in healthcare delivery, imaging continues to prove its worth through documented cost savings and improved patient outcomes. We recently saw this with Medicare%u2019s decision to cover heart scans. When the data is fully evaluated, the value of this integral technology cannot be denied.



Andrew Whitman
Executive Director
Medical Imaging & Technology Alliance (MITA)

Insurers are doing a poor job distiguishing between unnecessary medical imaging, and life-saving medical imaging. The net result is irreparable harm to thousands of patients.

Hopefully, a recent class action lawsuit settlement involving major insurers will help:

http://www.hmoset...2-08.pdf
>
> Here is one analysis of its impact:
> "The settlement consideration includes a guaranteed cash payment of over $128 million to class members. In addition, the settling defendants have agreed to implement important business practice changes that bring the estimated value of the entire settlement consideration to well over $1 billion. These changes include commitments to do the following:
> * Implement a definition of > "> medical necessity> "> that ensures that patients are entitled to receive medically necessary care as determined by a physician exercising clinically prudent judgment in accordance with generally accepted standards of medical practice;
> * Use clinical guidelines that are based on credible scientific evidence published in peer-reviewed medical literature (taking into account Physician Specialty Society recommendations, the views of physicians practicing in the relevant clinical areas, and other relevant factors) when making medical necessity determinations;
> * Provide physicians with access to an independent medical necessity external review process;
> * Establish an independent external review board for resolving disputes with physicians concerning many common billing disputes;
> * Pay for the cost of recommended vaccines and injectibles and for the administration of such vaccines and injectibles;
> * Not automatically reduce the intensity coding of evaluation and management codes billed for covered services;
> * Ensure the payment of valid clean claims within fifteen (15) days for electronically-submitted claims and thirty (30) days for paper claims;
> * Provide fee schedules to physicians;
> * Establish a compliance dispute mechanism to address disputes regarding the Blues> '> compliance with the agreement;
> * Establish and/or maintain physician advisory committees; and
> * Provide ninety (90) days> '> notice of changes in practices and policies and annual changes to fee schedules.
> These practice changes are expected to result in hundreds of millions of dollars in real savings to physician practices throughout the country. The end result will leave doctors more time for patient care instead of dealing with what was a complex, cumbersome, costly and frustrating system put in place by Blue Cross and Blue Shield plans.
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Unfortunately, our own experience with BCBS and NIA has been totally unsatisfactory:

March 27, 2008

Thomas G. Dehn, M.D., FACR
Chief Medical Officer
National Imaging Associates, Inc.
11050 Olson Drive Suite 200
Rancho Cordova, CA 95670
(via certified mail)

Re: NIA/Magellan/BCBSFL guidelines for PET and diagnostic CT


Dear Dr. Dehn,

I have not yet received a response to correspondence mailed to you and other representatives of NIA, Magellan, and BCBSFL on February 1st. Prompt attention to this matter is critically important to the health and safety of the many patients who have already been adversely impacted by your decisions.

We have previously discussed the dangers of Magellan / NIA / BCBSFL refusal to allow combined PET and diagnostic CT. Normal or benign findings can result in a false positive PET exam when diagnostic CT is not performed simultaneously. Examples include surgical clips, calcified granulomata, barium-filled colonic diverticuli, diverticulitis, lymphadenitis, brown fat, stress, muscle movement during test, injection sites, ovulation, insect bite, trauma, surgical or biopsy site, occult osteoporotic fracture, etc. Without information available only from fusing PET and diagnostic CT images captured simultaneously, many of these patients will be misdiagnosed. Performing diagnostic CT on a later date will provide less accurate diagnosis than PET combined with diagnostic CT, and also subject patients to additional radiation and contrast agents.

Of additional concern, I have recently learned from local representatives that it is now BCBSFL policy not only to deny diagnostic CT combined with PET, but also to allow diagnostic CT at a later date only if PET is positive. This decision is extremely disturbing. While PET is an extraordinary tool for cancer diagnosis and staging, it does not detect all cancers. False negative PET exams may be seen with many cancer types including mucinous carcinoma, some adenocarcinomas, neuroendocrine tumor, renal cell carcinoma, bronchoalveolar carcinoma, infiltrating lobular carcinoma, prostate cancer, and liposarcoma. Diagnostic accuracy is optimized when PET and diagnostic CT are performed simultaneously. This fact is well documented in the medical literature.

It is most unfortunate that Magellan / NIA / BCBSFL have elected to continue to follow imaging policies in conflict both with published Magellan / NIA guidelines and high standards of care. In addition to serious concerns this raises for our patients, we are also beginning to question the wisdom of providing BCBSFL insurance to our own staff members.


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In the absence of a response from Magellan / NIA / BCBSFL, we must begin sharing this information with patients and other providers, to help protect patients from potential harm by your misguided policies. Medicare, Tricare, and most other major insurance companies have not made similar judgment errors.

I understand that Magellan / NIA wishes to reduce imaging service expenditures for its insurance company clients, such as BCBSFL. Nevertheless, for the sake of patients, as well as the reputation of Blue Cross Blue Shield of Florida as an insurer, I hope you will reconsider your position regarding combined PET and diagnostic CT. It is critically important that you distinguish between state of the art imaging services, which can save both lives and insurance dollars, and inappropriate testing that should of course be curtailed.

Your prompt attention to this matter is again requested. This issue will not go away.


Sincerely,


Angel Williamson M.D.
Board Certified in Diagnostic Radiology, Nuclear Radiology, and Nuclear Medicine


Enclosures: Magellan / NIA Diagnostic Imaging Guidelines
Sample NIA Denials for Combined PET and Diagnostic CT

cc: Steven J. Shulman, CEO, Magellan Health Services (via certified mail)
Robert Lufrano, CEO, Blue Cross Blue Shield of Florida (via certified mail)
Thomas Lampone M.D., BCBSFL (via certified mail)
Kathleen Turley, Physician Relations Specialist, BCBSFL (via certified mail)
McMahon and Hadder Insurance
Ming Chen Chang M.D.
Ranjith Dissanayake M.D.
David Mann M.D.
Henry Hsiang M.D.
Dale Zorn M.D.
John Gage M.D.
James F. McKenzie, Esquire
CBS News
ABC News
NBC News
CNN News









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Inquiries from medical investigative reporters wishing to study these issues are welcomed.

Mike Williamson M.D.
Pensacola, FL
dmike330@yahoo.com