Blue Cross, Blue Shield decries proposed panel

January 18, 1992|By Ross Hetrick

Spurred by increasingly vocal complaints about how health insurers decide what procedures to pay for, Blue Cross and Blue Shield of Maryland defended its system yesterday and said a proposal to set up a regulatory panel would be unworkable.

There has been a growing number of complaints by patients, particularly in the area of drug and alcohol treatment, about health insurers denying payments for various types of treatment. In some cases, the denials came after the treatment was finished, leaving the patient with the bill.

Generally, health insurers will not pay for treatment that is considered experimental or unnecessary for a particular patient.

In reaction, some state legislators are planning to introduce a bill that would establish a panel to resolve such disputes. Maryland now has no formal body to settle such disputes, except for the court system.

The creation of the proposed panel was one of the issues discussed at a press conference held by Blue Cross yesterday to explain how the state's largest health insurer decides what is medically unnecessary.

"I'm skeptical about the availability of impartial and knowledgeable arbitrators," said Dr. Daniel T. McCrone, president and chief operating officer of Maryland Medical Services, the subsidiary of Blue Cross that determines the necessity of medical treatment for the people the company insures.

He said there might be a tendency for medical specialists to side with physicians in the disputes. On the other hand, Dr. McCrone said, his experience with boards made up of non-medical personnel indicates they have difficulty reaching decisions.

"My personal view is that it will not be workable," Dr. McCrone said.

A panel to resolve disputes about the medical necessity of certain procedures has been one of the topics considered by a subcommittee of the House Environmental Matters Committee. "I believe [a bill] will be definitely going in," said Del. Joan B. Pitkin, D-Prince George's, the chairwoman of the subcommittee.

The bill is being drafted, and Ms. Pitkin was unsure exactly who would introduce it. However, the intention of the measure is to create a pool of specialists who would be readily available to settle disputes. The number of specialists on a panel would range from one to three, depending on the case, she said.

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