Q & A with Jonathan Starkey: Catching the feds' attention with health insurance denials

Jonathan Starkey has earned one of the rare treats in journalism. He has seen his reporting prompt a major federal investigation of health care malfeasance. This is an honor usually only bestowed on the likes of Duff Wilson or Walt Bogdanich. Reporters at smaller papers have to settle for a pat on their back from their editor.

Starkey, who covers the business of health care at the Wilmington News Journal in Delaware, found out that Blue Cross Blue Shield of Delaware had been paying a claims management company incentives to deny people access to care.

Everyone knows that, in the United States, insurance companies have the power to decide who gets care and who does not. But Starkey showed how Blue Cross Blue Shield wasn't just making conservative business decisions. The company, according to a state investigation prompted by Starkey's work, was breaking the law.

The U.S. Senate's Committee on Commerce, Science, & Transportation took an interest, too, and underscored much of what Starkey had written. The committee's chairman, Sen. Jay Rockefeller said in a press release, "This practice is putting profits over people - and putting lives at risk. But some doctors are also part of the problem. Our investigation concluded that doctors, judged using their own standards, are clearly still ordering tests when their patients don't need them."  

Starkey graduated in 2008 from New York University's graduate school of journalism and started out doing freelance work for places such as the Washington Post and Newsday. The first part of our email interview is below. It has been edited for space and clarity. The second part will appear Friday.

Q: You have written a lot about Blue Cross Blue Shield of Delaware. What made you first start asking questions about their record of denying claims?

A: Our original stories focused on a 45-year-old Maryland man who had been denied a heart diagnostic test multiple times and landed in the hospital needing a quadruple bypass less than a month later. We got a tip that one of his treating cardiologists had fired off a letter to the state's insurance regulator, arguing that Blue Cross' denials put his patient's life at risk. So we submitted a request for that letter, and went from there.

As it turns out, the doctor was pretty upset about the whole situation, and he was able to put us in touch with his patient, Michael Fields. We first talked to Fields when he was in the hospital, and he has been open to talking to us since. Our first story actually ran as a companion story to a package on health care reform about a week before Congress passed the bill last March. We thought that Fields' situation said something about the health care system that statistics and legislative process-stories can't: that there are competing interests in control of a patient's health care and patients often have a hard time navigating the system.

Q: How did you know that you were onto something, that it wasn't just a couple of patients mad because their bills weren't paid?

A: This was definitely something I worried about, especially since the first story moved pretty quickly. We reported the original story in three days, I think.  I felt better after meeting Fields, sitting down with him at his house and reviewing some his records. I was able to see the requests for his tests and the denials from the insurance company and their contract claims reviewer. Having his doctor's letter to the insurance regulator also helped a lot.

Q: But what made you think that it was a trend beyond the Fields case? It could have just been a paperwork fluke, right? But you clearly knew you were onto something. Why is that?

A: We did reach out to people we trust to confirm that this wasn't an isolated case. We talked to doctors who were very concerned that many of their patients were being denied necessary testing. Also we reached out to insurance experts who could talk to us about how these types of cost-saving measures were becoming more common. Background conversations that helped me think through the issue have been just as important as on-the-record ones. We're still not sure how many patients found themselves in Fields-like situations, but the state found as many as six people submitted serious heart-related claims after a denial.

Q: What types of public records did you gather in doing these stories?

A: We frequently ran searches through the PACER system of the federal courts to see if insurance companies were facing lawsuits about denials elsewhere in the country. That produced a story about a Nevada woman suing Blue Cross' contracted claims reviewer, a Tennessee-company called MedSolutions, for denying a test for her husband. He died of a heart attack some months after the denial.

As the story progressed, we also looked into the claim that doctors over-order certain high-tech imaging tests because they stand to benefit financially. That meant reviewing Medicare Payment Advisory Commission reports to Congress. MedPAC reports are great because they are full of good Medicare data and readily available for anyone to find on the web.

We also got a tip that a local cardiology practice had been fined more than $600,000 by HHS to settle kickback claims related to high-tech imaging tests. So we requested that report from the Inspector General's office at HHS and wrote a story. That story was particularly interesting because the practice in question was where Fields' cardiologist, the one who fired off the letter, worked. The claims alleged that the practice was paying ordering doctors above-market fees to administer nuclear stress tests. HHS thought that may be convincing those doctors to order more tests than may be necessary.

Q: As far as the insurance records themselves, how did you go about finding out how many claims the company was denying?

A: There was no real good way to get claims data, so we just kept asking and we kept writing stories. Eventually, MedSolutions agreed to provide us with some numbers in an attempt to bolster their argument that they were only denying unnecessary tests. 

Next: How Starkey pressed insurers for details on cost-cutting measures

Title photo (home page) credit: Mykl Roventine via Flickr

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Q & A with Jonathan Starkey, Part 2: Tracking down patients' stories of insurance denials