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
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
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."