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Physicians Have Input Into HCFA, Pennsylvania Blue Shield Medical Policies

Physicians Have Input Into HCFA, Pennsylvania Blue Shield Medical Policies

PITTSBURGH--Physicians in Pennsylvania play a "very heavy" role in medical policy decisions for the Health Care Financing Administration (HCFA) and Pennsylvania Blue Shield, Brent O'Connell, MD, said at the Association of Community Cancer Center's 1995 On-cology Symposium.

Dr. O'Connell is vice president of Medical Affairs at Pennsylvania Blue Shield, the nation's largest Medicare Part B carrier. Pennsylvania Blue Shield handles 400,000 Medicare claims each day for Pennsylvania, New Jersey, Delaware, Maryland, the District of Columbia, and northern Virginia.

For Medicare, medical policies are developed both by HCFA and the local carriers, he explained. Sometimes, instead of setting a national policy for a certain procedure, the agency gives local carriers some guidelines and requests that they develop the policy and use it for their claims, he said.

Pennsylvania Blue Shield develops medical policy for both its Medicare and private insurance business through input from nearly 500 paid consultants throughout its Medicare service area.

For HCFA policy, the carrier advisory committee assists in the development of the final policy. Blue Shield policy has to be approved first by its medical affairs committee, made up of physicians elected by their peers across Pennsylvania. The policy then goes to the board of directors, and half of the board members are physicians.

"Your peers have a lot to do with the development of our policies, for example, decisions about coverage for a certain procedure," Dr. O'Connell said. "When we develop policy, we are responding to you."

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