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

Jonathan Starkey, who covers the business of health care at the Wilmington (Del.) News Journal, has managed to work a great investigation of health insurance company practices into his regular beat. His work has sparked state and federal investigations, and it should serve as a model for reporters in other states. Chances are good that what Starkey found is happening in your corner of the world, too.

The first part of our interview was posted Wednesday. The second part is below. It has been edited for space and clarity.

Q: When did you first interview company officials about these denials and did you share with them any of the evidence you had gathered?

A: We first interviewed Blue Cross after reviewing documents from (patient) Michael Fields and his doctor's letter to the insurance commissioner. We talked to their chief medical officer and were straightforward about what we'd seen and, generally, about what we intended to write. I think our first interview was two days before the story ran. They said federal privacy laws prevented them from talking about specific cases. Like MedSolutions, they also said they were only denying claims for unnecessary tests. 

Q: How has Blue Cross been to deal with?

A: They're very responsive, in that we get an answer to every question we ask.

Q: When did your focus turn to MedSolutions? You have done a great job of explaining that company's role in the process while keeping Blue Cross Blue Shield in the picture, too. Was there an attempt by the insurance company to blame everything on MedSolutions?

A: We brought them into the stories almost immediately, but we still focused on Blue Cross as the local company that was ultimately charged with making decisions. Blue Cross really did not put all the blame on MedSolutions, which is something we might have expected. They still contract with MedSolutions to review pre-authorization claims for CT scans, MRIs and PET scans. They don't require pre-authorization for nuclear cardiac scans anymore, but Aetna does still use MedSolutions to review upfront claims for those tests.

Q: And how has MedSolutions been to deal with?

A: MedSolutions has probably been more responsive than Blue Cross and definitely more willing to make a strong case for their services. They continue to defend the Fields denials.

Q: A big focus of the investigation by the state has been this contract itself that MedSolutions had with Blue Cross. In the contract, MedSolution was paid incentives if it hit a target of denying 20 percent of preauthorization requests. The state says that contract violated state law. I have dealt with a lot of health care attorneys over the years, and I found it hard to believe that a company as savvy as Blue Cross Blue Shield would have put something in place with their legal department's approval that was illegal. Could this be an argument over semantics?

A: I just had a conversation with someone else who asked the same question. It's hard for me to make any informed comment on the legal advice they received, but they have backed off the provision. We first reported about the guaranteed savings provision last spring, after identifying the provision in materials that Blue Cross sent to the U.S. Senate Commerce Committee, which was investigating its denials. Blue Cross defended the savings provision initially, saying it didn't provide an incentive for denying tests that may be warranted otherwise. We found out in reading the state's findings that, in the midst of the investigation last year, Blue Cross actually stripped the guaranteed savings provision from its MedSolutions contract.

Q: Your most recent stories have focused on four Delaware patients who were denied nuclear cardiac stress tests and ended up needing emergency heart-related procedures. I've asked this before when there are stories based on something bad that happened to a few patients. And I've written plenty of those stories myself. But why are four patients newsworthy?

A: Maybe I could have put this into better perspective in that recent article. Here's one way to look at it: MedSolutions was only handling pre-authorization for nuclear cardiac tests for about 9 months for Blue Cross, from July 2009 to April 2010. In that time, there were actually six patients who presented a serious cardiac claim after a denial. On average, that's one every six weeks.

Q: The experience of those patients and others was clearly interesting enough to draw the attention of the U.S. Senate, which launched an investigation in March 2010. This month, the Committee on Commerce, Science, and Transportation released a report that credited your work. What did that report find that surprised you and what do you think it missed?

A: I think I should probably stay away from this one.

Q: You have been doing all this work on top of a very busy schedule. You have more bylines in one day than some reporters have in a week. How have you fit in the time to go deep in your Blue Cross reporting?

A: To be fair, that may be an exaggeration. But editors running the newsroom here place a premium on enterprise work off of every desk, not just from our investigative team, which I am not a part of. They give us time to do work that they feel is important. So every week you can find some piece of watchdog work coming out of the education staff or the business desk or the city staff. And it's not a huge staff, so reporters support the work of other reporters. There are three business reporters here, for example, me being one of them. As I was working on this project, my two colleagues stepped up and reported and wrote more on a daily basis. I do the same when they are working on their own projects.

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