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Post date: June 23 2008

Attorney General Cuomo Announces Agreement With Excellus And Carecore To Ensure Cancer Patients Get Timely Critical Care Services

ROCHESTER, NY (June 24, 2008) - Attorney General Andrew M. Cuomo today announced an agreement with Excellus BlueCross BlueShield and CareCore National LLC ending a long-standing dispute with physicians and streamlining critical care decisions. In a separate agreement, Excellus also adopted the Attorney General’s Doctor Ranking Model Code, which has become the national standard for the industry on this issue.

Last fall, Excellus launched a program that quadrupled the number of tests requiring preapproval. The implementation of the program had administrative problems, including the fact that Excellus and CareCore would not disclose their preapproval criteria to doctors until after denying a test.

Physicians and patients complained to the Attorney General’s Office and Excellus agreed to delay the launch of the proposed program. Excellus, CareCore, and physician and patient advocates worked cooperatively with the Attorney General to fashion today’s reforms.

Under the agreement announced today, doctors specializing in cancer treatment will not have to obtain approval before ordering tests known as CAT scans, the most frequently ordered test for cancer patients. In addition, other doctors who have a track record of complying with insurance requirements can gain “fast track” status and be exempt from the preapproval process as well.

“Prompt diagnosis can be a matter of life and death,” said Cuomo. “Controlling costs need not mean compromising patient care. Today’s agreement strikes the right balance because all stakeholders-doctors, patients, and insurers-had a voice in the solution. I applaud Excellus and CareCore for helping craft these reforms, which ended a cumbersome approval process and protects the integrity of the doctor-patient relationship.”

Rochester-based Excellus is the largest not-for-profit insurer in New York State. Excellus and its affiliates serve approximately 1.87 million people in 31 counties. CareCore, based in Dutchess County, is the largest radiology management company in the United States, serving 24 million people.

Today’s agreement was forged in consultation with the Monroe County Medical Society, with input from the Onondaga Medical Society and numerous physician organizations and hospitals in the region.

Under the agreement announced today, Excellus and CareCore will:
Disclose, in user-friendly language on their websites, the clinical criteria for approving radiology tests;
Exempt oncologists ordering scans for Excellus BCBS cancer patients;
Provide fast-track status, meaning a waiver of the Excellus approval requirement, for physicians whose imaging referrals for Excellus BCBS patients are approved at least 95% of the time for specific kinds of tests;
Give physicians at risk of losing the Excellus fast-track status notice and a right to explain why their ordering patterns have changed;
For certain conditions, such as multiple sclerosis, make preauthorization for Excellus members good for up to 180 days;
Make decisions on urgent requests within 3 hours of receipt of the request (emergencies are already exempt by law);
Answer the telephone within an average of 30 seconds, and handle the call within an average of five minutes; and
Cut in half the number of tests requiring preapproval from Excellus BCBS, from 252 to 125.

Jamie E. Kerr, M.D.,Vice President and Chief Medical Officer for Utilization Management of Excellus BlueCross BlueShield, said, “We want to thank the Attorney General and his staff, as well as our local physicians for working with us to meld an agreement that addresses the collective concerns of all sides. We are agreeing to hold ourselves to higher and speedier standards for radiology review than what the law requires and what is common practice within the industry-both statewide and nationally.”

CareCore’s Senior Vice President and Medical Director Joel Canter said, “CareCore would like to thank the Attorney General for his efforts to encourage all of the interested parties to arrive at a collaborative agreement. We support the Attorney General’s efforts to promote transparency for consumers and providers navigating the health care utilization management process. We are pleased that as a result of this effort, CareCore will be a participant in a program that is designed to assure that quality and clinically appropriate diagnostic imaging services will be accessible to Excellus subscribers.”

Consumer advocacy and provider organizations praised the agreement as a model of transparency and collaboration.

Mark Cronin, American Cancer Society Vice President for the Lakes Region in Rochester, said, “We applaud the Attorney General for his leadership in bringing about this agreement, and we thank the Monroe County Medical Society and Excellus BlueCross BlueShield for working together to ensure timely patient access to healthcare. Because surviving cancer is often related to detecting it early, delays in these circumstances could literally cost a patient his or her life. The agreement being announced today demonstrates again that in this community, we achieve the best results when we collaborate to reach our common goal of accessible, high-quality, appropriate and affordable health care.”

Leslie F. Algase, M.D., Immediate Past President of the Monroe County Medical Society,said, “Physicians needed access to ordering criteria at the outset of the radiology management program. The physician community applauds the Attorney General’s efforts to make the prior authorization process transparent by insisting that evidence-based ordering criteria be made available to physicians and other health care professionals. The agreement directly affects our ability to provide high quality care for our patients. The program changes and accompanying requirements for accountability and timely access will do much to alleviate our concerns that patient care will be delayed by administrative requirements.”

Onondaga County Medical Society President Thomas A. Bersani said, “The Onondaga County Medical Society is pleased to join with the Medical Society of the State of New York, the Monroe County Medical Society and the American Cancer Society in thanking Attorney General Andrew Cuomo and his staff for once again showing tremendous leadership in addressing another important health issue of great concern to patients and physicians. It is a credit to all involved that the agreement establishes a transparent process with criteria clearly defined for the benefit of patients, physicians and their offices.”

Medical Society of the State of New York President Michael H. Rosenberg, M.D., said, “The Medical Society of the State of New York congratulates Attorney General Cuomo and his staff, the Monroe County Medical Society and Excellus BlueCross BlueShield on a job well done. Once again, our Attorney General has used diplomacy and hard work to achieve a result that is good for New York. Through this important agreement, we all now have an efficient, effective and transparent radiology pre-authorization process that puts patients first, as it must be. Everyone involved with making this agreement a reality is to be commended.”

Excellus is the largest insurer in the Rochester and Syracuse regions, serving at least half of those markets. Excellus and its affiliates have approximately 872,000 members in Rochester, 549,000 in Syracuse and Central New York, 289,000 in Utica, and 165,000 in Buffalo. Approximately 839,000 Excellus members are subject to the radiology preapproval program.

Doctor Ranking Agreement

Also today, Excellus signed an agreement with the Attorney General adopting the Attorney General’s Doctor Ranking Model Code. Excellus does not currently rank physicians for cost-efficiency or quality but will apply the Model Code should it decide to use a doctor ranking program in the future.

Under the Doctor Ranking Model Code, insurers will:
Ensure that rankings for doctors are not based solely on cost and clearly identify the degree to which any ranking is based on cost;
Use established national standards to measure quality and cost efficiency, including measures endorsed by the National Quality Forum (NQF) and other generally accepted national standards;
Employ several measures to foster more accurate physician comparisons, including risk adjustment and valid sampling;
Disclose to consumers how the program is designed and how doctors are ranked, and provide a process for consumers to register complaints about the system;
Disclose to physicians how rankings are designed, and provide a process to appeal incorrect rankings; and
Nominate and pay for the Rx who will oversee compliance with all aspects of the new ranking model.

“I commend Excellus for joining other major insurers in adopting our Doctor Ranking Model Code,” said Cuomo. “The core principles of the Code are transparency and accuracy of information for consumers and doctors, and oversight of the process. The Code was developed with the input of national consumer advocacy and medical organizations, and it has become the national standard in this emerging area.”

“We fully support the Attorney General’s position on physician rankings,” said Jamie E. Kerr, M.D.,Vice President and Chief Medical Officer for Utilization Management of Excellus BlueCross BlueShield. “Any system for ranking practitioners would-and should-have uniform standards for measurement and those standards need to be readily available and easily understood by consumers and providers alike to be meaningful.”

Several of the nation’s largest health insurance companies have agreed to adopt Cuomo’s Doctor Ranking Model Code and use it nationwide: CIGNA Healthcare, Aetna, Empire Blue Cross Blue Shield, UnitedHealthcare, Oxford Health Plans, Group Health Incorporated (“GHI”) and Health Insurance Plan of Greater New York (“HIP”), which are subsidiaries of EmblemHealth, Inc., and MVP Health Care and its affiliate Preferred Health.

The agreement announced today concerning radiology services is the result of an investigation led by Kathryn E. Diaz, Senior Trial Counsel in the Health Care Bureau, under the supervision of Timothy A. Clune, Chief of the Health Care Bureau, and Linda A. Lacewell, the head of the Attorney General’s Healthcare Industry Taskforce. The doctor ranking agreement is part of a separate industry-wide initiative by the Taskforce.