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Bad press turns reasonable medical denials into question marks

Late last week, Sen. Jay Rockefeller (D-W.Va.) announced that the U.S. Senate Committee on Commerce, Science and Transportation was expanding an ongoing investigation into whether insurers in Delaware are denying medically necessary diagnostic heart stress tests, reports the News Journal. Rockefeller sent letters to both Hartford, Conn.-based Aetna Inc. and Bethesda, Md.-based Coventry Health Care Inc., requesting detailed information about the insurers' coverage denials for nuclear stress tests. In March, Rockefeller sent a similar letter to Blue Cross Blue Shield of Delaware in Trenton. All three insurers use evidence-based guidelines from MedSolutions to determine whether tests should receive authorization. The Senate investigation comes on top of a state investigation that has been opened by Delaware Insurance Commissioner Karen Weldin Stewart.

These federal and state investigations threaten yet another storm that could impact health insurers nationally. Why? Not because there is something definitively wrong with MedSolutions' or other companies' guidelines. Not because insurers are denying medical care, willy-nilly, without regard to the health and safety of their members. It doesn't take a rocket scientist to figure out that many Americans who have insurance get worried about a specific health problem, such as heart disease, and want to be tested, whether or not such tests are medically necessary.

The problem rests in uber-denials, the term I use to classify those few, absolutely bone-headed denials of either coverage or care that, while often eventually overturned, get widespread media attention across the nation and portray health plans as blood-sucking penny-pinchers rather than reasonable gatekeepers of medical care.

Two examples leap to mind: On the coverage side, Blue Cross Blue Shield of Texas recently reversed its decision to deny coverage for a newborn because the baby was born with a pre-existing condition. On the care side, Aetna recently had to reverse course in Missouri. A woman was left owing more than $100,000 in surgical bills that Aetna initially refused to pay. The surgeon and the hospital had called the insurer to obtain pre-certification of services and were told that pre-certification was unnecessary. When the claims were submitted, Aetna denied them because the providers hadn't obtained a predetermination of coverage. The woman has received a "happy ending," with Aetna deciding to pay for the surgery, reports the St. Louis Post-Dispatch.

But neither Blue Cross nor Aetna wins any points in terms of public perception. Nor does any health insurer. No matter how such cases are resolved, the public and state and federal officials take away a negative perception of the industry--and start looking at every denial as unreasonable. Insurers need to take steps to ensure that bad publicity doesn't result in onerous restrictions on their ability to deny unnecessary care. - Caralyn

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