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Delaware Blues - $325K

Payer: Blue Cross Blue Shield of Delaware

Penalty:  $325,000

Why: The insurer was recently hit with a large fine for denying cardiac tests. More specifically, the insurer was found to have "deficiencies" in its nuclear cardiac exam pre-authorization process, according to the Insurance and Financial Advisor.

Those deficiencies led Blue Cross to wrongly deny 73 physician orders for cardiac nuclear imaging studies for reasons such as insufficient information and a scan ordered without a doctor having seen the patient in more than 30 days, according to state and federal investigations.

What now: The insurer has agreed to underwrite a pilot program, developed by the American College of Cardiology (ACC), that aims to reduce inappropriate testing. As part of the agreement, Blue Cross will pay an annual fee of up to $100,000 toward the ACC's FOCUS program.

However, if Blue Cross doesn't commit to the program for at least three years, it faces an additional $300,000 fine.

Following the Delaware Blues' failed attempt to impose prior authorization on patients, the Medical Imaging & Technology Alliance (MITA) and the Access to Medical Imaging Coalition (AMIC) have called on Congress to reject the Blue Cross Blue Shield Association's (BCBSA) proposal for Medicare to use prior authorization for advanced imaging services, reports HealthcareIT News

"It's ironic that Blue Cross Blue Shield of Delaware was taken to task by the state insurance commissioner for denying patient care as a result of using prior authorization for imaging services, yet their national association chooses to advocate that Medicare adopt a similar scheme," said Tim Trysla, executive director of AMIC. "The Delaware Insurance Commissioner's decision underscores the ineffectiveness and negative consequences of prior authorization and it would be irresponsible to enact these tools more broadly."

Lesson learned: Thanks to the Delaware Blues' fine--and potential future penalties, should it violate it's agreement--insurers might reexamine their testing and imaging policies. Despite associated cost savings, payers ought to make sure that prior authorization requirements won't reduce access to necessary diagnostic and screening services, and therefore, compromise care.

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