Mindy dreaded having to find out if she had lung cancer.
After a dark spot showed up on an image of her lung last March, the Maple Grove mother of three steeled herself for the follow-up CT scan in late May to see if the nodule had grown. But the bad news she received at the imaging center that day came from her insurer, Blue Cross Blue Shield of Minnesota, which refused to pay for the scan because it determined it wasn’t medically necessary.
“To not know if you have a cancer is an awful feeling,” said Mindy, who is using a pseudonym because her family doesn’t yet know her health status. “And then to find out the CT is denied? Wow, OK. That insurance company just played God — that’s how I felt in that moment.”
An increasing number of Minnesotans covered by Blue Cross health plans are finding that their scans and medical procedures are being denied, even though their doctor said the care is needed and would be in the Blue Cross network.
The increasing trend is intentional. Dr. Craig Samitt, the company’s CEO, told the Star Tribune that Blue Cross is taking bold action to force change in a health care system that is unsustainably expensive.
The action is so bold that the state hospital association this month asked the attorney general to investigate whether Blue Cross is abandoning its legal responsibilities to patients and hospitals by imposing new limits on needed care, or the payments for that care.
Samitt, the internal medicine doctor who became CEO of Minnesota Blue Cross last July, said the insurer is pushing hard to cut the costs of unnecessary care by implementing a new system for prior authorizations and precertifications. He sees it as part of the answer to an existential crisis facing U.S. health care at large.
“We can’t just be a claims and network company as a health plan,” Samitt said from his office in Eagan. “I worry that, if costs continue to rise unsustainably, Medicare for All is a very possible outcome. I worry that if we don’t reinvent our industry from the inside out, someone will reinvent us from the outside in.”
Minnesota Blue Cross, a not-for-profit, outsourced its prior-authorization reviews last August to the 1,100 doctors and nurses who work for a company called eviCore, a for-profit company based in South Carolina that is owned by one of Blue Cross’ competitors, Cigna. EviCore works in all 50 states, and has more than 25 years’ experience in the field, including working with other health plans covering Minnesotans.
EviCore processes medical necessity paperwork and prior authorizations for Minnesota Blue Cross’ Medicare Advantage plans and its fully insured commercial accounts, including small- and large-group plans and individual plans (but not self-insured commercial members or Medicare supplement customers.) The scrutiny focuses on seven categories: laboratory services, medical oncology, radiation therapy, radiology, cardiology, musculoskeletal pain and sleep management. It doesn’t make determinations on hospital admissions.
“Prior authorization is very common, and it’s been around for many years,” eviCore Chief Medical Officer Eric Gratias said via e-mail. “The programs we do provide for [Blue Cross] are no more restrictive than what we provide for other health plan partners across the country. Our evidence-based guidelines are completely transparent and available to anyone on our website.”
When Samitt was asked about experiences like Mindy’s, in which eviCore ruled that there was no documented medical necessity to justify the advanced imaging, Samitt said Blue Cross has high standards for administrative efficiency that it expects eviCore to follow.
“As I have said, I expect no delays. If this is an administrative delay, and the answer should have been received months earlier, that is absolutely an issue that we should be responsible for and accountable for, and fix,” Samitt said.
However, the problem may have been that the CT scan wasn’t justified by eviCore’s care guidelines, which take into account the risks and benefits of imaging and what evidence says about how often such scans are medically necessary. “One of the challenges in health care is that we believe that more care delivers higher, better outcomes,” Samitt said. But, “in some instances, too much imaging can be dangerous.”
The denial letter eviCore sent to Mindy contained this explanation: “Your records show that you have a known or suspected problem with your chest. They do not show results of a recent chest X-ray that were not normal. By recent, we mean during the last 60 days. Advanced imaging, detailed picture study, is not supported without these results.” When she finally got the CT scan in July, under a different insurer, the results showed three nodules instead of one.
EviCore’s Gratias said that in the past the firm has uncovered situations like a pregnant Medicaid patient who received 22 CT scans, which created “tremendous risk to the unborn child,” and a 2-year-old patient who received 19 scans in one month’s time. “Twenty to 50% of all imaging tests may be redundant or unnecessary, and the radiation dose from a single CT scan can be 100 to 500 times higher than a chest x-ray,” he said.
Outsourcing prior authorization work is becoming more common. Other major insurers use companies like AIM Specialty Health, which is owned by the Indiana-based Anthem health plan, or Magellan Health, which is in the process of finding an acquirer.
Mark Berglund, an independent insurance broker in Minnetonka, said it’s good that someone is holding medical providers accountable for the costs and necessity of care. And it will take an insurer as large as Blue Cross, which has more Minnesota members than any other insurer, to make an impact, he said.
“Care providers will have to follow Blue Cross’ lead,” Berglund said in an e-mail. “I would imagine the other insurance companies will start requiring more prior authorizations as well, and that will help keep premiums and copays from rising in the future.”
Executives with Minnesota Blue Cross and eviCore are fluent in the language of 21st century health care reform, embracing value, evidence and collaboration and disdaining unjustified variations in cost and quality. They note studies that show 30% of all health care spending doesn’t improve patient care and that hospitals are often the most expensive places to have diagnostic tests done.
Critics like the Minnesota Hospital Association said they don’t oppose efforts to screen referrals for care. It’s the execution at eviCore and Blue Cross that they say is so bad that they believe it may violate state laws against fraud and deception.
So far neither the attorney general nor state officials have weighed in with an opinion on the issue.
“The problem with Blue Cross is not that it has prior authorization. It’s that it’s incompetent at managing its prior authorization,” said Matt Anderson, senior vice president for policy at the hospital trade group. “The manner in which Blue Cross and its subcontractor are administering prior authorization is resulting in delayed and denied care for patients that is medically necessary ... [and] denied payments to not just hospitals, but mental health providers and clinics across the spectrum.”