The five Blue Cross Blue Shield Plans of New York have agreed to implement independent external review of claims denied on the basis of medical necessity. The new policy, effective Jan. 1, replaces the Blues' internal appeals programs.
The new appeals process will be modeled on Empire Blue Cross Blue Shield's existing procedure regarding coverage of experimental treatments. Under that system, a patient and physician submit a request for external review, which is forwarded to one of two outside groups, the Medical Care Ombudsman Program or the Economic Cycle Research Institute. MCOP or ECRI selects a reviewing physician, who renders a binding decision within 72 hours, at Empire's expense.
Empire spokesperson Deborah Bohren says the process for experimental treatments "helps us evolve our internal medical policy" by staying on top of viable, cutting-edge treatments before studies are published about them. "It also has something of a sentinel quality," she says, in effect, screening out specious requests for coverage. An internal analysis of the first 10 months of 1997 shows that the external reviewers upheld 60 percent of Empire's coverage decisions regarding experimental treatments.
Together, the five plans cover more than 6 million people.