MINNEAPOLIS, 8:00 a.m. CST, March 1 --The Minnesota Medical Association (MMA), has asked the Commerce Commissioner to investigate potentially unlawful activities of HealthHelp, a company engaged by Medica to provide high-tech imaging “consultation” services, and has recommended that a cease-and-desist order be issued until the investigation is completed. The MMA is a professional association for physicians with more than 11,000 members throughout the state.

The MMA asserts that HealthHelp’s review of the appropriateness of high-tech imaging services constitutes utilization review. This is potentially unlawful since the company is not licensed to provide utilization review in Minnesota.

In January Medica began to require physicians who order CT, MRI or PET studies to contact HealthHelp and participate in a “consultation” to determine the medical appropriateness of the order.

If a physician disagrees with the first HealthHelp contact, a second level of “consultation” is required with a nurse reviewer. If there is still disagreement about the appropriateness of the ordered study, the physician is referred to a HealthHelp radiologist for a “consultation.” This process must be completed in order to obtain a reference number.

Effective March 1, 2007, Medica will begin denying payment to radiologists for any outpatient high-tech imaging claim submitted without the HealthHelp reference number.

The MMA alleges that HealthHelp may be in violation of Minnesota’s utilization review law (62M.02, Subd. 20), which defines utilization review as the “…evaluation of the necessity, appropriateness, and efficacy of the use of health care services, procedures, and facilities, by a person or entity other than the attending health care professional, for the purpose of determining the medical necessity of the service or admission…”

The law also defines “certification” to mean “…a determination by a utilization review organization that an admission, extension of stay, or other health care service has been reviewed and that it, based on the information provided, meets the utilization review requirements of the applicable health plan and the health plan company will then pay for the covered benefit…” (62M.02, Subd. 5)

In January, the MMA asked Medica and other Minnesota health plans to withdraw or suspend their high-tech imaging program and work with the MMA to understand the use of high tech imaging in Minnesota and address any problems that might exist.

Demanding “consultations” for all imaging procedures is a waste of energy, time, and money, MMA leaders told the health plans. It puts an administrative burden on clinics, increases health care costs and adds to the time patients must wait for an imaging procedure.