Health Team

Blue Cross approval policy gives cardiologists heartburn

Posted February 23, 2012

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— Cardiologists across the state are lining up to oppose a new Blue Cross Blue Shield of North Carolina policy that requires patients to get approval from the insurer before getting an echocardiogram.

Dr. Jenie Comives, Blue Cross' senior medical director, said multiple studies have shown that 15 percent of cardiac echo tests are ordered inappropriately.

"We spent $17.5 million last year on these tests," Comives said Thursday. "Our goal is not to have a high denial rate. Our goal is to have everybody using and ordering these appropriately."

Since the prior authorization policy went into effect Jan. 15, Blue Cross says, doctors statewide have ordered about 2,000 cardiac echoes. Three-quarters of those were immediately approved, and the rest were delayed so more information could be submitted.

Eighty-five cardiac echoes were denied, but the insurer says 51 of those patients were given a different test.

Dr. Jack Newman and other cardiologists contend that Blue Cross is getting between patients and their doctors.

"With so much oversight being done, it's impacting patient care," said Newman, part of the Raleigh Cardiology practice.

Echocardiogram, cardiac echo, cardiac test Blue Cross says some cardiac tests are unnecessary

He called cardiac echo tests "as basic as a stethoscope" and said the tests are relatively inexpensive and pose few safety risks.

"I had a patient a couple weeks ago who drove two hours to see me," he said. "(Because of the new policy,) she has to come back for a stress test – another two-hour drive back and forth."

Newman said he fears other insurance companies will institute similar prior approval policies.

"Of course they'd prefer not to have to go through an authorization process. I don't blame them for that," Comives said. "Right now, this is the only tool we have available to ensure our members are in fact getting the right test."

Still, Blue Cross is discussing other possible alternatives with the American College of Cardiology, she said.


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  • ladyblue Feb 24, 2012

    I have fibromyalgia -So do I, and i'm sorry for your pain, but the patches didn't help me as it was too many places to put them hurting at same time. lol..they are denying my electrodes to my TENS machine, the only thing that has kept me off of pain meds with deterioted disks in my back, for a decade.. I guess now they want me to take narcotics??? they seem to approve them quite freely...The drug companies are a big monster in this pricing scam as well...

  • macy Feb 24, 2012

    I have fibromyalgia - the doctor prescribed Lidoderm patches which work miracles for the pain. BCBS denied the claim for them saying that they are only approved for patients that have suffred from Shingles. These patches are $10.00 each and I have been prescribed 3 patches a day.....for the amount I need for each month that is almost $1,000 per month for medicine that I need. So, the bottom line is, I am in severe pain 24/7 -- thanks BCBS!!

  • ladyblue Feb 24, 2012

    Seems nothing has changed....the republican backed insurance companies as usual

    Some people need to think before they comment if they want people to take them serious.

    Now I just hope they don't stop allowing me to get my yearly test done since I have an artificial valve and they have to look at it to make sure it's still working properly.. guess i'll be on the don't allow list.

  • za2duke Feb 24, 2012

    Fine line between curbing medical costs and getting in the way of patient care.

  • amedlin Feb 24, 2012

    BCBS is a pain in my chest. They denied pain patches for the pain I am having in my chest because they did not think they were necessary. Are they in my chest and now how bad my chest hurts. They really make me made as fire. We pay them all this money then they tell us what medicine or test we can have.

  • kermit60 Feb 24, 2012

    How about looking into which doctors are ordering tests that aren't necessary and making the guilty ones get approval. Some seem to order every test available because they can.

  • suncat Feb 24, 2012

    ProzacDispenser - If you were drinking that much coffee a day...then why bother going to the doctor complaining of heart palpations in the first place? Obviously, you knew what the issue was and could have corrected it yourself. Don't blame the doctor for correctly responding to your concerns by making sure your heart issue was not due to a nerve block or valve problem instead of caffeine overload.

  • suncat Feb 24, 2012

    If an insurance company denies an important diagnostic test and the patient dies or suffers grave physical injury, can that insurance company be sued for negligence?

  • gman007 Feb 24, 2012

    I love how this is all boiled down to 'Doctor v Insurer'. But there are 'checks and balances'. The HMOs do have nurses and doctors to review questionable claims for 'medical necessity' because doctors, individual and group practices, hire extremely creative billing agents. And taxman, if you ran an HMO, one of those creative billers would have you bankrupt in 6 months. And yes, we the patients are caught in the middle. But this isn't the 'big' problem in healthcare. It's the malpractice insurers. We are back in the day of the midwives because doctors are staying away from OB simply because of malpractice insurance. It's why when you are hospitalized you get sepearate bills for the doc, the hosp, the lab, the radiologist, etc. etc. A hospital could never afford the malpractice insurance for all of it. This is the first thing that needs to be controlled.

  • dumbhick Feb 24, 2012

    It all boils down to greedy insurance cutting into the profits of greedy doctors(who were cutting into the profits of the greedy insurance companies). The patient gets batted back and forth between country club fees.