If this is an administrative delay, and the answer should have been received months earlier, that is absolutely an issue that we should be responsible for and accountable for, and fix,” Samitt said. When Samitt was asked about experiences like Mindy’s, in which eviCore ruled that there was no documented medical necessity to justify the advanced imaging, Samitt said Blue Cross has high standards for administrative efficiency that it expects eviCore to follow. Our evidence-based guidelines are completely transparent and available to anyone on our website.” “The programs we do provide for are no more restrictive than what we provide for other health plan partners across the country. “Prior authorization is very common, and it’s been around for many years,” eviCore Chief Medical Officer Eric Gratias said via e-mail. It doesn’t make determinations on hospital admissions. EviCore works in all 50 states, and has more than 25 years’ experience in the field, including working with other health plans covering Minnesotans.ĮviCore processes medical necessity paperwork and prior authorizations for Minnesota Blue Cross’ Medicare Advantage plans and its fully insured commercial accounts, including small- and large-group plans and individual plans (but not self-insured commercial members or Medicare supplement customers.) The scrutiny focuses on seven categories: laboratory services, medical oncology, radiation therapy, radiology, cardiology, musculoskeletal pain and sleep management. Minnesota Blue Cross, a not-for-profit, outsourced its prior-authorization reviews last August to the 1,100 doctors and nurses who work for a company called eviCore, a for-profit company based in South Carolina that is owned by one of Blue Cross’ competitors, Cigna. I worry that if we don’t reinvent our industry from the inside out, someone will reinvent us from the outside in.” “I worry that, if costs continue to rise unsustainably, Medicare for All is a very possible outcome. “We can’t just be a claims and network company as a health plan,” Samitt said from his office in Eagan. He sees it as part of the answer to an existential crisis facing U.S. Samitt, the internal medicine doctor who became CEO of Minnesota Blue Cross last July, said the insurer is pushing hard to cut the costs of unnecessary care by implementing a new system for prior authorizations and precertifications. The action is so bold that the state hospital association this month asked the attorney general to investigate whether Blue Cross is abandoning its legal responsibilities to patients and hospitals by imposing new limits on needed care, or the payments for that care. Craig Samitt, the company’s CEO, told the Star Tribune that Blue Cross is taking bold action to force change in a health care system that is unsustainably expensive. That insurance company just played God - that’s how I felt in that moment.”Īn increasing number of Minnesotans covered by Blue Cross health plans are finding that their scans and medical procedures are being denied, even though their doctor said the care is needed and would be in the Blue Cross network.
“And then to find out the CT is denied? Wow, OK. “To not know if you have a cancer is an awful feeling,” said Mindy, who is using a pseudonym because her family doesn’t yet know her health status.
But the bad news she received at the imaging center that day came from her insurer, Blue Cross Blue Shield of Minnesota, which refused to pay for the scan because it determined it wasn’t medically necessary. Mindy dreaded having to find out if she had lung cancer.Īfter a dark spot showed up on an image of her lung last March, the Maple Grove mother of three steeled herself for the follow-up CT scan in late May to see if the nodule had grown.
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