Blue Cross defends new policies that some say restrict needed care

Despite sharp criticisms this week, Blue Cross Blue Shield of Minnesota is not backing down from new policies that hospitals and patients said greatly restrict in-network health care.

Blue Cross officials on Friday rejected the allegation that they established new policies and procedures with the specific intent of denying or delaying needed care. Rather, the not-for-profit insurer said it is working with a for-profit contractor in South Carolina called eviCore to enforce evidence-based guidelines for approving and paying for care. But sometimes that does result in denials.

To hospitals and some Blue Cross customers, the aggressive denials seen this year are tantamount to fraud and deception, since members can't access the benefits purchased by them or on their behalf. Minnesota Attorney General Keith Ellison's office is looking into the hospitals' concerns, after receiving a formal complaint from the Minnesota Hospital Association earlier this week.

Minnesota Blue Cross Health Services President Dana Erickson said the policies that went into effect earlier this year requiring new prior authorizations and evidence-based practice guidelines are common across the industry and are intended to lead to the best outcomes for patients, providers and the insurer.

But Matthew Anderson, senior vice president for policy with the state hospital trade group, said the way the state's Blue Cross plan is rolling out the requirements is far outside the norm.

"The difference with Blue Cross is, it is doing it so poorly that it is interfering with care. And because there is such a large volume of mistakes and process errors and time spent trying to navigate their process that they've crossed the line," Anderson said, adding the Blue Cross needs to change its process "or turn it off."

The hospital association's 27-page complaint, which was sent to Ellison and the state commissioners of finance and health this week, said Blue Cross Blue Shield of Minnesota is probably breaking state laws against deceptive trade practices, fraud and requirements that health plans include sufficient numbers of providers in their networks to ensure services are available to all enrollees. The letter also accuses Blue Cross of deliberately setting up "an administrative and procedural labyrinth" that interferes with care being delivered.

"Unfortunately, far too many patients today receive care that's not evidence-based, which can be unsafe, time-consuming, and mentally, emotionally and financially draining," Dr. Eric Gratias, eviCore's chief medical officer, said in an e-mail Friday. "We help patients avoid these harms by making sure their care meets the latest evidence-based guidelines from nationally recognized medical societies, as well as new scientific evidence from recently published medical literature."

Kelly Doran, who stepped down as CEO of real estate development firm Doran Cos. in May, said he opted to have his company switch insurance providers midyear because he was so dissatisfied with how eviCore and Blue Cross were treating the company's roughly 200 health plan enrollees.

Doran, whose lung cancer was successfully treated several years ago, said eviCore denied a routine computed tomography (CT) scan that he gets every six months for follow-up care. He later learned his doctor would have to call eviCore directly in order to receive approval for the scan, even though Blue Cross allowed the same scan for the past three years.

"How is that more cost-effective in the medical business to have a doctor call ... eviCore to get approval?" Doran said. "Why are they doing it? Because doctors don't want to make those calls. It's a deliberate strategy."

Doran's wife also experienced a delay when a doctor's request for an MRI was denied, forcing her to wait several more days before getting the scan. Doran then discovered a litany of problems after polling company employees. One person's routine mammogram, ordered by her primary-care doctor, was denied coverage. Another employee's spouse, who has MS, was denied a routine MRI ordered by her internal-medicine doctor. One plan member was denied coverage for a sleep study ordered by a doctor for sleep apnea.

Blue Cross' Erickson said the insurer is working directly with physicians to help them understand the need to practice evidence-based medicine, even in a climate when evidence can change over time. For example, CT scans and mammograms deliver radiation to the patient and carry a "very small" risk of causing disease — a risk that the Food and Drug Administration said should be weighed against the benefit of the imaging.

Erickson said Blue Cross' work with eviCore is intended to "advance some of our oversight capabilities" over high-cost procedures and high-use areas for which there's evidence of overuse. The company is open to working with doctors who recommend treatments or diagnostics that fall outside evidence-based treatment guidelines.

"The goal is not to impede care for our members," she said.