Troubleshooter

Doctors claim Blue Cross restricts heart test

Thursday, February 23, 2012

A group of cardiologists claims North Carolina's largest medical insurer is getting in the way of providing their patients with a crucial medical test they rely on.

"It's a basic tool that cardiologists use on a daily basis," explained Dr Jack Newman.

Newman said the test is an echocardiogram - or an "echo."

"An ultrasound of the heart is like women who get ultrasounds for babies. There's no danger to it, it's an ultrasound. We put cold glop on the chest, put a microphone, and take pictures of the heart," said Newman.

But despite being non-evasive and relatively inexpensive, Blue Cross and Blue Shield of North Carolina is now requiring doctors to get pre-approval for the tests.

"You've got doctors who are seeing the patients, listening to the patients, examining the patients, who are looking at other diagnostic tests, and they are making a clinical decision that we think this is the best thing to do. And all of a sudden now, someone else on the end of a computer screen, or at the end of a telephone, who does not know the patient, is making a decision that seems to be a clinical decision - that's where they're getting between the patient and the doctor," said Newman.

Dr. Newman told ABC11 he fears it could put his patients' health in jeopardy.

"My concern is that I could make the diagnosis potentially that day, and now there is a delay in that care. And sometimes, and we've been finding now if that is being denied, then perhaps that test won't get done and that patient won't get the diagnosis or something could happen," said Newman.

Newman said he's had to wait as little as 5 minutes for preapproval, but as long as 40 minutes, followed by a denial, and he then had to take the next step of a peer-to-peer review.

"It's such the administrative burden that we don't get reimbursed for. We get nothing special if we fit criteria or did things a certain way. There's nothing to help with those added costs," said Newman.

And Dr. Newman isn't alone in his frustration. Four state chapters of National Health Organizations all co-signed a letter asking BCBSNC to not require preapproval for echos - saying it "will impose a substantial hardship on both patients and physicians, with little benefit to BCBS of NC and its subscribers."

They also say it's burdensome for the doctors and will force many patients to make a second office visit - and spend more money.

Blue Cross and Blue Shield of North Carolina - with more than 3.5 million customers - told ABC11 it understands all those concerns, but they're not changing their policy.

BCBS doctor Genie Komives cited national studies that suggest echocardiograms are inappropriately used 15 percent of the time.

"The risk is the follow-up testing the patient may have to incur if they have a false positive test or the test is done unnecessarily," she said. "Our belief is we want to improve care for our members and they are getting the right tests at the right time and the right place."

Dr. Komives said doctors can easily get preapproval online if their patient fits the guidelines set forth by their own industry.

"Basically, we're asking the physicians to follow their own guidelines - the ACC guidelines - for the most part. In this case, [it] just seems like the right thing to do," said Komives.

She also said Blue Cross research shows that 70 to 80 percent of preapprovals average 4 to 5 minutes.

"Yes indeed, there are sometimes when a provider does not get the authorization immediately, and it may take an hour or two to sort through that information, which ultimately could lead to approval, but that is a relatively small percentage of cases. The majority of cases are going through and getting approved on the initial review," said Komives.

Some may wonder if the policy change is about cutting costs and saving money. Dr. Komives said not totally.

"This is an example of one - when you look at the $17.5 million of total cost - the evidence that is in the doctor's own medical literature of the 15 percent overuse of the test - or using it not within the guidelines - that seems like an area that is important enough that it is worthy of doing something about," said Komives.

Dr. Newman said he's all for cutting waste, but his first priority is to protect his patients.

"You can never see this without ultrasound. Ultrasound is what makes the diagnosis. I can see the function in the squeezing of the heart. I can see in this one particular picture if there are leaky heart valves which there are in here and if this patient came to me today and said 'I'm short of breath,' I could do this today, sit down with them right afterwards, answer the question, and then do we need to put you on medicines to help fix your problem," said Newman.

But Newman said he now has to get a preauthorization for the test.

"Now I have to get authorization for this, for this simple test to do, they'd have to come back another day to be able to do this, when I could have done it in 20 minutes here," he said.

Newman said the Medicare rate for a basic resting echocardiogram on his patients is less than $200, and any restriction in his use of it is like sending him back in time to the 1960s.

In addition to the four state chapters of National Health Organizations which asked BCBS to drop the requirement, the North Carolina Academy of Family Physicians said it sent a letter of concern to Blue Cross about the new pre-approval process.

Blue Cross said the pre-approval is only required for an outpatient setting such as in a doctor's office - not in the Emergency Room.

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