Lawmakers grill HMSA over policy critics say delays care

HMSA defends cost-cutting policy that requires doctors to get CTs, MRIs preapproved, delaying care
(Image: Hawaii News Now)
(Image: Hawaii News Now)
(Image: Hawaii News Now)
(Image: Hawaii News Now)

HONOLULU (HawaiiNewsNow) - Lawmakers heard from doctors and patients Friday who say a new HMSA policy that requires all advanced x-ray procedures to get pre-approval is putting people's health at risk.

The policy went into effect in December, and is now the focus of legislation that would prohibit health insurers to put in place preauthorizations that cause undue delays in medical treatment.

Under the policy, doctors who need advanced x-ray procedures (like MRIs or CT scans) in order to make a diagnosis or determine care must seek preauthorization from a third-party agency, the Arizona-based National Imaging Associates.

Physicians say the preauthorization process is creating a dangerous delay, but HMSA says it's preventing unnecessary testing.

"Physicians nationally have implemented this themselves and are actually doing a public outreach campaign about the concerns and health-risks associated with unnecessary radiation," said Jennifer Diesman, HMSA's vice president of government relations.

Doctors disagree that the policy benefits patient health.

"HMSA as well as all the others, they're insurance carriers. They're supposed to be paying for the care that's delivered. They're not supposed to be controlling it," said Dr. Richard DeJournett, a diagnostic radiologist, who has 35 years of experience with Koolau Radiology.

Dr. Kevin Christensen, an orthopedic surgeon with 34 years of experience, said some preauthorizations take a few hours but others take several days. He said he's heard other physicians who have waited for approval even longer.

"It's dynamically changed our ability to care by delaying information," he told lawmakers.

Lawmakers say House Bill 2740 is aimed addressing the situation, by putting the onus on health insurers to ensure care isn't being delayed. Testimony on the measure before the House Judiciary committee Friday was emotional and heated.

At one point, the husband of a patient addressed lawmakers. Holding back tears, he said his wife was denied an MRI and he couldn't understand why.

"She's at home suffering severe pain while she waits," he said.

A number of doctors also testified about the impact the new practice has had. "Every single MRI I have submitted has been denied," said Dr. Linda Rasmussen, an orthopedic surgeon at Castle Hospital.

Another physician raised issue with the fact HMSA is relying on a mainland company to make critical decisions for Hawaii patients. "Do you want those decisions to be made by off-shore non-experts?" the doctor asked.

HMSA says its new policy only applies to outpatient care, not emergency rooms or hospitals. The insurer also argues preauthorization prevents overuse of medical services that could unintentionally cause harm.

"I think that the issue really is around safety and risk of undue radiation," Diesman said.

Lawmakers pressed for clarification on the point.

"What is the side effect of an MRI? What is the harm of an MRI?" asked Dr. Richard Creagan, a Hawaii Island representative, after correcting Diesman when she said MRIs expose patients to radiation. "I'm not a physician," Diesman replied.

HMSA says preauthorization for such procedures is already required for Medicare and Medicaid. The company maintains its priority is the needs and safety of their members.

"There really is no patient safety argument to be made with respect to this because it doesn't apply to emergent or urgent circumstances," Diesman said.

Doctors say that's not the case. One doctor said a 32-year-old woman recently had a stroke while waiting two weeks for an MRI.

"Now that she's damaged, who takes this liability? The insurance company? NIA? How about the medical directors of HMSA that put her on hold for two weeks?" asked Dr. Stephen Holmes, who served as The Queen's Medical Center Chief of Radiology. "It's frustrating, anxiety producing and it does delay care," Holmes said, who called the policy as "solely a cost-containment measure."

HMSA is the state's largest health insurer, with more than 730,000 members.

Prior to instituting the new policy in December, most Hawaii doctors didn't need pre-approval for non-emergency advanced x-ray procedures.

HB 2740 specifies that insurers, but not health care providers, are liable for civil damages caused by undue delays for preauthorization. That's a stipulation doctors asked for.

"If the problem was the doctor not being able to get pre-approval, it will allow the doctor to be able to say, 'This wasn't my fault. It was the insurance company's fault,' and transfer the liability," said Bert Sakuda, of the Hawaii Alliance of Justice.

The bill has passed through two committees and now heads to the full House for a vote.

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