Lawmakers respond to HMSA policy shift on imaging

Lawmakers are proposing a bill that would prohibit health insurers from requiring pre-authorization for medical services, following an outcry from doctors and patients.

On Dec. 1 Hawaii Medical Service Association began requiring all physicians in its network to go through a third party, Arizona-based National Imaging Associates Inc., to approve diagnostic imaging tests — including MRIs, computerized tomography (CT) scans and other cardiac-related procedures — in an effort to avoid unnecessary procedures and reduce costs. Before the new policy, most doctors were given a waiver, known as a gold card, that allowed them to skip the pre-authorization step.

The policy change resulted in complaints that HMSA’s new process is delaying critical imaging tests, resulting in harmful consequences for patients. House Bill 2740 aims to ban requirements that cause “undue delay in receipt of medical treatment or services” and specifies that insurers are liable for civil damages caused by any holdups for pre-authorization.

“Any delay in the delivery of health care is an undue delay,” Dr. Richard DeJournett, a Honolulu diagnostic radiology specialist, testified before House Health Committee members at a hearing Monday, adding that his practice saw a 33 percent drop in CT scans since HMSA imposed the policy. “That is a substantial drop. We can’t take care of our patients. There will eventually end up being adverse health outcomes for some of our patients.”

HMSA lobbyist Jennifer Diesman told lawmakers that pre-authorizations are a regular part of the health care system put in place to protect patients.

“The programs we have in place on the imaging side have also been in place for 10 years. What HMSA did is put the pause button on and said we need to figure out the utilization,” she said. “Could we have changed things here and there? Probably. There’s nothing that prevents physicians today from ordering the scan they need to order and dealing with the insurance process after. No one intends to cause undue delay, obviously. It is a process that will continually be revised.”

Diesman said the proposed legislation is much broader than just pre-approval for imaging exams and “potentially more dangerous” because it could significantly increase health care costs.

HMSA promised to restore waivers for certain doctors once it identified which providers are ordering excessive diagnostic imaging exams.

“This has really been devastating to physician practices. It is enough to close some doors,” said Dr. Chris Flanders, executive director of the Hawaii Medical Association, representing 1,100 physicians. “The more devastating has been the effect on patient care. Extended times between diagnosis and treatment means poorer outcomes. We want to see this come to an end.”

Honolulu medical malpractice attorney Rick Fried said he has been waiting two weeks now to get an MRI to determine whether there is a tear in his rotator cuff.

“In the past for sports injuries I’ve been able to get the test immediately or the next day. I’m in a position that if it were urgent I could go pay for it, but unfortunately most people aren’t in that position,” he said. “Very few people can pay for the costs of these expensive tests, which are typically the definitive diagnostic tool.”

HMSA’s pre-authorization policy could lead to litigation for delays in imaging exams, Fried said, adding that he was recently alerted to two patients with tumors whose scans were held up, and a third person who had a stroke while waiting two weeks for pre-authorization.

“The statute that has been proposed makes the insurer liable for injury to a patient caused by undue delay. It does properly immunize the doctor if they were trying to do the right thing and weren’t permitted to,” Fried said. “If there was real evidence that doctors in Hawaii were abusing it, then I could see this being in place, but there isn’t. We’re one of the lowest users in the country.”

Karen Masunaga, a 57-year-old retired registered nurse, couldn’t get a CT scan at an urgent-care clinic even after “sharp stabbing pains” persisted throughout the holidays. After six days of waiting for approval from HMSA, her pain intensified until she finally ended up in the emergency room, where she was able to get the scan.

“What if it was something really critical? Without a CT scan nobody’s going to diagnose it for months. It’s kind of too late if you’re dead,” she said, adding that HMSA eventually denied her initial request for a scan. “They’re tying the doctor’s hands behind their backs by not allowing the doctor to have the information he needs in order to make a correct diagnosis. Had I not gone to the ER, I would’ve continued suffering unnecessarily. They’re expecting a doctor to make a diagnosis by looking outside a person’s body when the pain is on the inside. It’s really scary. These are patients’ lives.”