After RBM challenge, Del. requires Blue Cross to adopt appropriate use

The Delaware Insurance Commissioner has ordered Blue Cross Blue Shield of Delaware to adopt the American College of Cardiology’s FOCUS program, based on national medical society-developed appropriate use criteria.

The order comes on the heels of questions from patients and the media regarding effective delivery of care under Blue Cross Blue Shield of Delaware’s (BCBSD) use of prior authorization for cardiac nuclear imaging via radiology benefit managers (RBM), which were used as gatekeepers for access to medical imaging. In April, the Delaware Department of Insurance ruled that the payor had violated state law by inappropriately denying cardiac imaging exams.

Tim Trysla, executive director of Access to Medical Imaging Coalition (AMIC), applauded the decision and noted that there is no research showing that RBMs achieve the long-term cost savings that proponents claim they do.

In a recent American Medical Association survey of 2,400 physicians, 63 percent said that they typically wait several days for a response to a prior authorization request and 13 percent said they generally wait more than a week.

Alternatively, appropriate use criteria programs using clinical decision support and education have proven effective and successful in driving quality care without compromising patient access, across a host of medical settings and studies.