The national Blue Cross and Blue Shield Association last week announced the development of a nationwide set of medical standards to guide the clinical practices and reimbursement of physicians and other providers.
The uniform medical policy is the first of a set of initiatives aimed at attracting large employers whose work forces cross state lines.
Nine of the biggest Blues plans formed a company called the National Account Consortium a year ago to enhance their ability to serve national accounts by consolidating medical, marketing and technical support services.
The consortium's goal is to integrate the largely autonomous statewide plans into a cohesive and consistent business unit, said Alex Rodriguez, vice president and medical director.
By developing uniform standards, the coalition seeks to demonstrate a scientific basis for its medical policies as well as consistent claims-payment decisions from state to state. "Our goal is to have 100% compliance between published clinical policy and all the claims adjudicated," he said.
That hasn't always been the case. Until recently, the national Blues organization produced medical policy recommendations, but individual plans developed policies on their own.
No more. Clinical policies will be formally used for national accounts by the consortium's member plans, which represent more than 20 million members, and will be followed on a voluntary basis by other plans, Rodriguez said. "If you have variances in policy, you're going to have variances in the care provided," he said.
The new standards focus on more than 200 medical evaluations and treatments that involve complicated diagnoses and decisionmaking, including high-risk, high-cost treatments such as bone-marrow and organ transplants and sophisticated diagnostic imaging.
Participants in the consortium are the Blue Cross and Blue Shield plans in Connecticut, Illinois, Massachusetts, Michigan, Ohio and Texas; Pennsylvania Blue Shield; Blue Cross of Western Pennsylvania; and Blue Shield of California.