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 FinancingAdministration (HCFA) and Pennsylvania Blue Shield, Brent O'Connell,MD, said at the Association of Community Cancer Center's 1995On-cology Symposium.

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

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

Pennsylvania Blue Shield develops medical policy for both itsMedicare and private insurance business through input from nearly500 paid consultants throughout its Medicare service area.

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

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