Lawmakers ask HMSA, doctors to agree on imaging pre-authorization
COURTESY HMSA
Mark Mugiishi: He is HMSA’s chief medical officer.
Lawmakers are urging Hawaii Medical Service Association and its doctors to come to a compromise on a controversial new HMSA policy requiring doctors to get pre-authorization from a mainland company before ordering imaging tests for patients.
HMSA began requiring on Dec. 1 all physicians in its network to go through a third party, Arizona-based National Imaging Associates Inc., to approve diagnostic imaging exams — 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, introduced after the Honolulu Star-Advertiser published a story about the policy, aims to ban requirements that cause “undue delay in receipt of medical treatment or services” and specifies that insurers would be liable for civil damages caused by any holdups for pre-authorization.
“In health care, moments really do matter,” said Dr. Scott McCaffrey, president of the Hawaii Medical Association, representing 1,100 physicians, at a Thursday hearing before the Senate Commerce, Consumer Protection and Health Committee. “It is the reason for 911, ambulances and emergency rooms, and nothing should ever delay the physician’s ability to reach early, accurate diagnoses.”
Dr. Mark Mugiishi, HMSA’s chief medical officer, said that the policy is necessary as Hawaii’s imaging utilization costs are about 9 percent higher than the national average in the commercial market for people who have insurance through their employers.
Other research shows that the state’s imaging rate for Medicare, the government health insurance program for seniors, was 33 percent lower than the national rate in 2014 — the second lowest in the nation, according to the Hawaii Health Information Corp., a nonprofit that analyzes local health care data.
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“Pre-authorization programs for advanced imaging are commonplace,” Mugiishi said, “because advanced imaging has become a problem of over-utilization in our country and something that really does need to be addressed so that we can spend our health care dollars on things that really matter and are necessary for our population.”
HMSA has restored waivers for 22 out of the 58 providers in the state who order more than one imaging test per day, Mugiishi told lawmakers. HMSA has more than 2,000 doctors in its network.
Sen. Roz Baker, chairwoman of the Senate Commerce, Consumer Protection and Health Committee, has asked HMSA and its doctors to reach a compromise before a decision is made on the bill.
Physicians who testified at the hearing agreed that imaging tests should be screened for medical appropriateness, but they are hoping to work with HMSA on how to make the process more efficient.
One suggestion is for doctors to use software to immediately determine whether a test is necessary rather than waiting for a mainland company to make a determination. Another idea is to allow the Hawaii Medical Association and the American College of Radiology to help assess the screening process locally to reduce delays in imaging exams.
In a private meeting after the hearing, HMSA agreed to meet with the Hawaii Medical Association and its physicians to work out a possible compromise, said Dr. Scott Grosskreutz, a Hilo radiologist, who was in the closed-door session.
“The physicians are hopeful after meeting with HMSA that we can find a better way to approve tests so that there are no longer delays in patient care,” he said.
19 responses to “Lawmakers ask HMSA, doctors to agree on imaging pre-authorization”
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Dr. Mugiishi is such a sellout! He and HMSA are more concerned about cost to the Insurance Carrier than actual patient care! If an organization of 1100 doctors says that the delays are affecting patient care vs what the Insurance Carrier says, I would be more inclined to believe the 1100 doctors! Someone should take his doctor card away because he’s breaking the first rule of medicine which is to do no harm and yet his actions are causing harm to patient care requiring them to wait until their condition worsens before they get the imaging scans that their primary care physician needs to make the proper diagnosis. If you ask me, the Legislature should go ahead and pass this bill anyways to make sure that the patient doesn’t get hurt in the future!
Agree
Creed as a doctor is to treat every patient and provide every procedure to make sure that his or her patient is treated medically. Apparently Dr. Mugiishi forgot his creed when he went to medical school.
You have to remember that he is being PAID by HMSA ….for some like Mugiishi, everything goes out the window when $$$$ is involved.
This is a pretty big deal…A doctors training should not be usurped by slower and less qualified means so that insurance companies can make even higher profits at the cost of a patients health.
Four suggestions for legislation:
1) Prohibit any financial incentives, compensation or inducements the 3rd party may have to reject a pre-cert. Whether this is done on a per-case basis or through quarterly or annual goals and quotas, there should be no financial incentive to reject a pre-cert request. The committee should find out what is in the HMSA contract now.
2) Require anyone, insurance carrier or 3rd party, who reviews a request for a pre-cert, to be licensed in the state of Hawaii as a physician or whatever the appropriate medical license is for the nature of the pre-cert request. Have true peer review. The current system allows the 3rd party to subcontract out the review to yet another party anywhere in the world. This will also cut down on the business practice of using 3rd parties.
3) Add the element of time. Put a clock on the review, say 48 hours after submission, or the request is automatically approved. This will serve the patient (remember him/her?) the best and prevent the insurer using time as a de facto rejection by dragging out the review process and frustrating with doctor and patient. If a request is rejected, it must be accompanied by the reason why, an alternative therapy or procedure, and the name AND license number of the reviewer. This will keep the insurer/3rd party honest by preventing them from rejecting the request out-of-hand.
4) Require quarterly reports, to be available to the public, stating the number of pre-cert requests an insurer received, the number approved, disapproved and pending. This will give the employers and those individual who buy insurance a basis of comparison between insurers as part of their decision making process.
I’m sensitive to all three sides of this agreement: insurer, doctors and patient.
Excellent! Those are great suggestions.
Excellent points
Now if the Hawaii legislature can get in gear, we might have healthcare that’s reasonable, reflects our increasing premiums! I thought the legislature represented us and not the insurance companies……this sounds familiar
Why has HMSA management not been analyzing the data to highlight the outlier physicians that order images from the onset? Those are the folks that may need extra reviews. Their broad brush one shoe fits all policy is too prescriptive and causes the patients potential harmful delays to diagnosis and prolonged pain.
Also, as brought up by others, what are the specifics of HMSA’s contract with NIA Magellan? To make this effort worthwhile they have to save more money than they cost. Is there some sort of intentional or unintentional quota or incentive for NIA to deny claims or are they just counting on the “hassle factor” to frustrate physicians and patients into giving up?
Lastly, what is HMSA doing to control their own operating costs? How does their overhead and management staff size compare to like sized Blue Cross HMO’s in the mainland? What is the cost/benefit of their big contracts with Well-Being and CVS? As they are a semi-monopoly, who is monitoring and providing oversight for their performance?
Why hasn’t the fact that we treat Micronisian patients more than any other state. Isn’t one of the basic part of cancer diagnoses are these types of procedures.
How about pre-authorization for everything — drug prescriptions, fixing broken limbs, each individual blood tests, every medical opinion to a patient. Why have doctors? Why pay HMSA?
Unfortunately, medical care is run by the insurance companies uneducated clerks that sit behind a computer with an unapproved button, next to the not authorised button. They know nothing of medicine. They are trained to save insurance money. Many procedures and medicines are rejected and require a one on one from your doctor to the insurance company.
Why blame HMSA.
HMSA is simply operating within limits set by Obamacare.
Medical Doctors have been known to overmedicate/overprescribe to their patients. (SA article 5/5/15-Doctors targeted amid rise in painkiller deaths.)
Many Doctors practicing in the islands are not Board Certified.
It would only be fitting to have an independent board that ‘specializes’ in thorough review of cases prior to conducting these very invasive MRI’s/CT scans deeming them medically necessary. At times these tests are ordered by the doctors which don’t find the problem due to prescribing the wrong test.
CT scan is NOT suitable in visualizing the spinal cord, ligaments and the tendons.
CT scan is the treatment of choice for brain hemorrhages, discovering the extent of cancer and pneumonia, and confirming abnormal chest CXR (X-rays).
Doctors take offense to being questioned about their diagnosis/treatment. Get over it. They have to get it 100% correct otherwise it could result in a patient’s death and turn into a lawsuit.
Bottom Line is the patients welfare is critical to diagnosis.
Why was it a closed-door session? How can you wait 48 hours for someone in an accident?
We Pay Hmsa for services. Hmsa literally decides if any physician is properly credentialed, educated, good enough, to provide care to us Hmsa subscribers
Now Hmsa tells our doctors that while they are Hmsa approved as physicians, that someone else, off island, possibly not even practicing anymore, and Not Even Familiar with our care, is The One to decide if we get imaging.
This is ludicrous.
Oh, and you should understand that this mainland physician, is Paid to deny imaging. That’s their job or why would they be in between us and our physician?
So all the hand wringing about physicians getting “paid” for sending patients to imaging, excess radiation (I don’t think an MRI uses radiation?, over use of imaging ( didn’t this article show that Hawaii physicians actually use Less imaging than mainland?) is a total smokescreen by Hmsa to deny us proper imaging and Care
The public is askinbg lawmakers to stop their conflicts and accept less pay.
How about asking THE PATIENTS that are being affected.
SUCK-UPS! When will they protect the local people…never! It is all about profits…forget about lives. They don’t matter.