HMSA pre-authorization policy delaying critical tests, some doctors say

Jerome Fukuhara knew something was wrong with his heart when it got harder and harder to breathe while walking around the block.

In February the 52-year-old Salt Lake resident went to his doctor, who wanted him to get a heart scan to check for blockages in his arteries. The doctor’s request for a test was denied by the Hawaii Medical Service Association, the state’s largest health insurer, which began requiring pre-authorization on imaging tests in December.

Then in March, Fukuhara had a follow-up with the doctor, who told him to go to the emergency room to get the exam done immediately. HMSA does not require pre-authorization for emergency room or hospital patients. Fukuhara’s test revealed one of his arteries was nearly 100 percent blocked, two others were 90 percent obstructed and a fourth was 80 percent closed. Four days after the test, he was undergoing quadruple bypass heart surgery.

“If I had waited for approval, he’d be dead,” said Fukuhara’s doctor, Dr. Calvin Wong, chief of cardiology at the Queen’s Medical Center.

HMSA said its new pre-authorization policy did not cause a delay in Fukuhara getting the care he needed. The insurer contends that Wong did not submit the medical records required to get the heart scan approved, did not tell HMSA the test was urgent and did not take advantage of an appeal process in a timely manner.

Doctors cite delays

However, the new pre-authorization policy has stirred opposition from many Hawaii doctors who say it is delaying critical imaging tests, resulting in harmful consequences for patients.

HMSA on Dec. 1 began requiring the roughly 3,000 physicians in its network to go through National Imaging Associates Inc., a subsidiary of Scottsdale, Ariz.-based Magellan Health Inc., to approve diagnostic exams — including MRIs, computerized tomography (CT) scans and other cardiac-related procedures — for its 720,000 members.

Previously, HMSA gave most Hawaii doctors a waiver, known as a gold card, that allowed them to skip the pre-authorization process. Physicians with gold cards could order an exam for a patient and get it done within a few days. Now doctors say many of their requests are initially denied and that “standard” appeals can take up to 30 days. HMSA said the average time for pre-approvals is 24 hours once all the necessary information is submitted by the doctor.

To help speed pre-authorization in urgent cases, HMSA revised its December policy, notifying physicians via email Feb. 22 that it would issue “immediate approval” for tests if doctors attest that the case is clinically urgent.

‘The hassle factor’

The fact remains that pre-authorization does delay outpatient testing.

“It’s the process that’s the killer,” Wong said. “They (HMSA) overwhelmed us with the process. I get 10 to 25 pre-authorizations a week. In cardiology everything is urgent. Everybody is a time bomb, and I don’t know when the time bomb is going to explode.”

Wong did eventually appeal Fukuhara’s case, sending HMSA 24 pages of clinical records. Upon receiving the documents, Fukuhara’s test was approved, but by then he had already checked in at the emergency room.

The Hawaii Medical Association, a trade group representing 1,900 physicians, is calling for the immediate suspension of the pre-authorization program. State lawmakers have also taken up the issue. House Bill 2740 would make HMSA legally responsible for deaths or other harm as a result of undue delays in testing. The bill is scheduled to be debated in conference committee today.

Dr. Christopher Marsh, a Honolulu internist, said doctors should have the authority to order tests immediately. “We have technology that’s so good, it’s crazy not to apply it. … We’re in the trenches. We’re on the line, but we have to get approval and run things by a panel of people we don’t even know who haven’t seen a sick person for a while. These guys don’t know what the hell they’re doing. It’s the hassle factor.”

Marsh said his Honolulu practice employs 10 staff to do the administrative work for two doctors.

“They are on the phone or the fax all day long trying to get our patients approved medications, imaging tests, referrals, etc.,” he said. “My beef is that this micromanaging of my day-to-day patient care is trashing my ability to take care of my sick patients.”

Dr. Jon Graham, a neurosurgeon at Queen’s, added, “They’re practicing medicine without a license by having guys on the mainland telling us how we should treat our patients, and yet if we get bad results, we’re liable. These people are telling us how to treat patients without even examining them. If I got a patient with a brain tumor and want to get a follow-up scan to see how much of the tumor is left, I have to get approval. It delays care and it delays treatment. It’s ridiculous.”

National Imaging Associates, the company that reviews pre-approval cases for HMSA, said on its website that it employs board-certified physicians and decides 450,000 requests a month from doctors around the country. NIA’s website said the company offers its clients “industry-leading clinical, operational, and financial resources that allow us to achieve bottom-line results and guarantee multi-year cost savings.” NIA didn’t respond when asked to comment for this story.

‘Put the brakes on’

Not all physicians think pre-authorization is unwarranted.

Dr. John Cogan, a cardiologist and clinical professor of medicine at the University of Hawaii’s John A. Burns School of Medicine, said prior authorization is necessary to safeguard patients and “because physicians do not police themselves.”

“There are physicians in every specialty that order tests inappropriately and do procedures inappropriately,” Cogan said. “Unfortunately, there are physicians that do not practice evidence-based medicine, who look for ways to increase income from doing tests that are moderately appropriate. They get the money from the tests (done in their offices). Since doctors don’t put the brakes on what they’re doing themselves, that is exactly why insurance companies feel they must do it. The insurance companies by default are practicing medicine.”

Cogan said the pre-approval process is tedious and costs him roughly $50 a patient, but he’s never had a legitimate test turned down once the correct information was submitted to the insurer.

HMSA said in an email, “Protecting the health and safety of our members is HMSA’s top priority. Our advanced imaging preauthorization program follows national guidelines developed by top physicians across the country.” When the policy was introduced, the insurer said pre-approvals would reduce unnecessary procedures, avoid patients being exposed to excessive radiation and reduce costs.

HMSA did not respond to the Star-Advertiser when asked:

>> How many pre-authorization requests has HMSA denied?

>> How much money has the policy saved HMSA?

>> Is HMSA tracking what happens to patients who are denied tests?

“Any decision that a doctor or patient does not agree with can be reconsidered,” HMSA said in its email. “This has happened with about 6 percent of these cases. … Just over half of these were overturned and were always the result of receiving the needed clinical information from the physician. We continually evaluate this program based on the feedback from physicians and patients.”

The company said the feedback has already led to several improvements including dedicated phone lines for doctor-to-doctor conversations, expanded hours to accommodate Hawaii physicians and the creation of a local physician advisory panel.

‘It’s overwhelming’

In Fukuhara’s case, Wong requested a “non-urgent” pre-authorization Feb. 12, according to HMSA’s records. National Imaging Associates tried unsuccessfully to let Wong know he needed to submit medical records with the pre-authorization, the insurer said. Wong said his office sent the documents by fax Feb. 15. NIA says it only received the fax cover and denied approval because it still hadn’t received the clinical information.

Wong said he did not contact HMSA or NIA again until after Fukuhara returned to his office for a follow-up visit March 2 and his symptoms had worsened. The next day, Wong appealed the denial of the heart scan. The delay in appealing the original HMSA denial was due to the added work his office has taken on due to the pre-authorization policy, he said.

“It’s overwhelming,” Wong said. “There are so many hoops you’ve got to jump through. We just don’t have the time. It’s a tremendous hassle factor. Everybody I talk to has the same problem.”

Fukuhara checked into the emergency room March 3, and the next day was given the nuclear heart scan, 22 days after his doctor determined he needed one. On March 5, Fukuhara had a cardiac catheterization, a procedure used to diagnose heart conditions, and on March 7 he had quadruple bypass surgery.

When Fukuhara returned home from the hospital March 12, he found letters from both HMSA and National Imaging Associates, dated March 4 and March 3 respectively, notifying him that an appeal had been approved.

“It was too late. I already had the bypass surgery,” Fukuhara said. “I couldn’t understand why HMSA (initially) denied the test. If they looked at what they’ve been paying for in the past 11 years for me medically, they would’ve seen that I’m a high-risk patient. If the cardiologist who I’ve been seeing for 11 years on a regular basis orders a test, there’s a reason. I don’t understand how they expect to save money doing this.”

Physician warned

When the Star-Advertiser asked HMSA about the Fukuhara case and another involving pre-authorization, the insurer’s attorney, Paul Alston, sent a letter to Wong stating that his requests were initially denied because they lacked clinical information, and once that information was sent, the denials were reversed. In Fukuhara’s case, “once that information was submitted — this time as an expedited request — approval was given in 27 minutes,” Alston wrote.

Alston then warned Wong about the steps HMSA could take if the doctor continued to insist that the delay of test approvals was harming patients.

“HMSA has asked that we tell you that — to a certainty — any implication that those patients were harmed by HMSA’s preauthorization requirements is false and defamatory,” Alston wrote. “If you do not immediately notify the media that these allegations are false, you (and anyone else involved in disseminating these false claims) will cause serious reputational harm to HMSA. Please be aware that HMSA is prepared to pursue its legal remedies to address the harm caused by publication of these claims.”

Hawaii doctors aren’t the only physicians unhappy about pre-approval policies.

The American Medical Association, the nation’s largest organization of physicians, conducted a survey in 2010 that showed 78 percent of doctors believe prior authorization is often unreasonable.

“Intrusive oversight policies that require physicians to get insurance company permission before providing care can delay patient access to medically necessary services,” said Steven Stack, AMA president, in an email. “The AMA continues to urge health plans to limit the application of prior authorization policies, or consider alternative approaches to control the cost of services and medications that reduce burdens on both patients and physicians.”