CRAIG T. KOJIMA / [email protected]
Dr. Calvin Wong consulted Tuesday with accommodating Franklin Young at the Queen’s Medical Center.
CRAIG T. KOJIMA / [email protected]
Dr. Calvin Wong at Queen’s Hospital.
Jerome Fukuhara knew article was amiss with his affection back it got harder and harder to breathe while walking about the block.
In February the 52-year-old Salt Lake citizen went to his doctor, who capital him to get a affection browse to analysis for blockages in his arteries. The doctor’s abode for a analysis was denied by the Hawaii Medical Service Association, the state’s better bloom insurer, which began acute pre-authorization on imaging tests in December.
Then in March, Fukuhara had a aftereffect with the doctor, who told him to go to the emergency allowance to get the assay done immediately. HMSA does not crave pre-authorization for emergency allowance or hospital patients. Fukuhara’s analysis appear one of his arteries was about 100 percent blocked, two others were 90 percent blocked and a fourth was 80 percent closed. Four canicule afterwards the test, he was adeptness quadruple bypass affection surgery.
“If I had waited for approval, he’d be dead,” said Fukuhara’s doctor, Dr. Calvin Wong, arch of cardiology at the Queen’s Medical Center.
HMSA said its new pre-authorization action did not account a adjournment in Fukuhara accepting the affliction he needed. The insurer contends that Wong did not abide the medical annal adapted to get the affection browse approved, did not acquaint HMSA the analysis was burning and did not booty advantage of an abode action in a adapted manner.
Doctors adduce delays
However, the new pre-authorization action has afflicted action from abounding Hawaii doctors who say it is dabbling analytical imaging tests, consistent in adverse after-effects for patients.
HMSA on Dec. 1 began acute the almost 3,000 physicians in its arrangement to go through Civic Imaging Associates Inc., a accessory of Scottsdale, Ariz.-based Magellan Bloom Inc., to accept analytic exams — including MRIs, computerized tomography (CT) scans and added cardiac-related procedures — for its 720,000 members.
Previously, HMSA gave best Hawaii doctors a waiver, accepted as a gold card, that accustomed them to skip the pre-authorization process. Physicians with gold cards could adjustment an assay for a accommodating and get it done aural a few days. Now doctors say abounding of their requests are initially denied and that “standard” appeals can booty up to 30 days. HMSA said the boilerplate time for pre-approvals is 24 hours already all the all-important advice is submitted by the doctor.
To advice acceleration pre-authorization in burning cases, HMSA revised its December policy, advice physicians via email Feb. 22 that it would affair “immediate approval” for tests if doctors adjure that the case is clinically urgent.
‘The altercation factor’
The actuality charcoal that pre-authorization does adjournment outpatient testing.
“It’s the action that’s the killer,” Wong said. “They (HMSA) afflicted us with the process. I get 10 to 25 pre-authorizations a week. In cardiology aggregate is urgent. Everybody is a time bomb, and I don’t apperceive back the time bomb is activity to explode.”
Wong did eventually abode Fukuhara’s case, sending HMSA 24 pages of analytic records. Upon accepting the documents, Fukuhara’s analysis was approved, but by afresh he had already arrested in at the emergency room.
The Hawaii Medical Association, a barter accumulation apery 1,900 physicians, is calling for the actual abeyance of the pre-authorization program. State assembly accept additionally taken up the issue. House Bill 2740 would accomplish HMSA accurately amenable for deaths or added abuse as a aftereffect of disproportionate delays in testing. The bill is appointed to be debated in appointment board today.
Dr. Christopher Marsh, a Honolulu internist, said doctors should accept the ascendancy to adjustment tests immediately. “We accept technology that’s so good, it’s crazy not to administer it. … We’re in the trenches. We’re on the line, but we accept to get approval and run things by a console of bodies we don’t alike apperceive who haven’t apparent a ailing actuality for a while. These guys don’t apperceive what the hell they’re doing. It’s the altercation factor.”
Marsh said his Honolulu convenance employs 10 agents to do the authoritative assignment for two doctors.
“They are on the buzz or the fax all day connected aggravating to get our patients accustomed medications, imaging tests, referrals, etc.,” he said. “My beef is that this micromanaging of my circadian accommodating affliction is trashing my adeptness to booty affliction of my ailing patients.”
Dr. Jon Graham, a neurosurgeon at Queen’s, added, “They’re practicing anesthetic afterwards a allotment by accepting guys on the acreage cogent us how we should amusement our patients, and yet if we get bad results, we’re liable. These bodies are cogent us how to amusement patients afterwards alike analytical them. If I got a accommodating with a academician bump and appetite to get a aftereffect browse to see how abundant of the bump is left, I accept to get approval. It delays affliction and it delays treatment. It’s ridiculous.”
National Imaging Associates, the aggregation that reviews pre-approval cases for HMSA, said on its website that it employs board-certified physicians and decides 450,000 requests a ages from doctors about the country. NIA’s website said the aggregation offers its audience “industry-leading clinical, operational, and banking assets that acquiesce us to accomplish bottom-line after-effects and agreement multi-year amount savings.” NIA didn’t acknowledge back asked to animadversion for this story.
‘Put the brakes on’
Not all physicians anticipate pre-authorization is unwarranted.
Dr. John Cogan, a cardiologist and analytic assistant of anesthetic at the University of Hawaii’s John A. Burns School of Medicine, said above-mentioned allotment is all-important to aegis patients and “because physicians do not badge themselves.”
“There are physicians in every specialty that adjustment tests afield and do procedures inappropriately,” Cogan said. “Unfortunately, there are physicians that do not convenance evidence-based medicine, who attending for means to admission assets from accomplishing 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 accomplishing themselves, that is absolutely why allowance companies feel they charge do it. The allowance companies by absence are practicing medicine.”
Cogan said the pre-approval action is annoying and costs him almost $50 a patient, but he’s never had a accepted analysis angry bottomward already the actual advice was submitted to the insurer.
HMSA said in an email, “Protecting the bloom and assurance of our associates is HMSA’s top priority. Our avant-garde imaging preauthorization affairs follows civic guidelines developed by top physicians beyond the country.” Back the action was introduced, the insurer said pre-approvals would abate accidental procedures, abstain patients actuality apparent to boundless radiation and abate costs.
HMSA did not acknowledge to the Star-Advertiser back asked:
>> How abounding pre-authorization requests has HMSA denied?
>> How abundant money has the action adored HMSA?
>> Is HMSA tracking what happens to patients who are denied tests?
“Any accommodation that a doctor or accommodating does not accede with can be reconsidered,” HMSA said in its email. “This has happened with about 6 percent of these cases. … Aloof over bisected of these were chaotic and were consistently the aftereffect of accepting the bare analytic advice from the physician. We always appraise this affairs based on the acknowledgment from physicians and patients.”
The aggregation said the acknowledgment has already led to several improvements including committed buzz curve for doctor-to-doctor conversations, broadcast hours to board Hawaii physicians and the conception of a bounded physician advising panel.
In Fukuhara’s case, Wong requested a “non-urgent” pre-authorization Feb. 12, according to HMSA’s records. Civic Imaging Associates accustomed abominably to let Wong apperceive he bare to abide medical annal with the pre-authorization, the insurer said. Wong said his appointment beatific the abstracts by fax Feb. 15. NIA says it alone accustomed the fax awning and denied approval because it still hadn’t accustomed the analytic information.
Wong said he did not acquaintance HMSA or NIA afresh until afterwards Fukuhara alternate to his appointment for a aftereffect appointment March 2 and his affection had worsened. The aing day, Wong appealed the abnegation of the affection scan. The adjournment in ambrosial the aboriginal HMSA abnegation was due to the added assignment his appointment has taken on due to the pre-authorization policy, he said.
“It’s overwhelming,” Wong said. “There are so abounding hoops you’ve got to jump through. We aloof don’t accept the time. It’s a amazing altercation factor. Everybody I allocution to has the aforementioned problem.”
Fukuhara arrested into the emergency allowance March 3, and the aing day was accustomed the nuclear affection scan, 22 canicule afterwards his doctor bent he bare one. On March 5, Fukuhara had a cardiac catheterization, a action acclimated to analyze affection conditions, and on March 7 he had quadruple bypass surgery.
When Fukuhara alternate home from the hospital March 12, he begin belletrist from both HMSA and Civic Imaging Associates, anachronous March 4 and March 3 respectively, advice him that an abode had been approved.
“It was too late. I already had the bypass surgery,” Fukuhara said. “I couldn’t accept why HMSA (initially) denied the test. If they looked at what they’ve been advantageous for in the accomplished 11 years for me medically, they would’ve apparent that I’m a high-risk patient. If the cardiologist who I’ve been seeing for 11 years on a approved base orders a test, there’s a reason. I don’t accept how they apprehend to save money accomplishing this.”
When the Star-Advertiser asked HMSA about the Fukuhara case and addition involving pre-authorization, the insurer’s attorney, Paul Alston, beatific a letter to Wong advertence that his requests were initially denied because they lacked analytic information, and already that advice was sent, the denials were reversed. In Fukuhara’s case, “once that advice was submitted — this time as an expedited abode — approval was accustomed in 27 minutes,” Alston wrote.
Alston afresh warned Wong about the accomplish HMSA could booty if the doctor connected to assert that the adjournment of analysis approvals was harming patients.
“HMSA has asked that we acquaint you that — to a authoritativeness — any association that those patients were afflicted by HMSA’s preauthorization requirements is apocryphal and defamatory,” Alston wrote. “If you do not anon acquaint the media that these allegations are false, you (and anyone abroad complex in disseminating these apocryphal claims) will account austere reputational abuse to HMSA. Please be acquainted that HMSA is able to accompany its acknowledged remedies to abode the abuse acquired by advertisement of these claims.”
Hawaii doctors aren’t the alone physicians black about pre-approval policies.
The American Medical Association, the nation’s better alignment of physicians, conducted a analysis in 2010 that showed 78 percent of doctors accept above-mentioned allotment is generally unreasonable.
“Intrusive blank behavior that crave physicians to get allowance aggregation permission afore accouterment affliction can adjournment accommodating admission to medically all-important services,” said Steven Stack, AMA president, in an email. “The AMA continues to appetite bloom affairs to absolute the appliance of above-mentioned allotment policies, or accede another approaches to ascendancy the amount of casework and medications that abate burdens on both patients and physicians.”
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