N.Y. payor loosens medical imaging rules for cancer patients

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Excellus BlueCross BlueShield Tuesday reported that it will no longer require oncologists to obtain approval before ordering CT exams for cancer patients, after nearly nine months of disputes between doctors and patient advocacy groups.

Under an agreement, the Rochester, N.Y.-based nonprofit payor will also remove the approval requirements for dozens of other diagnostic procedures and retract a controversial program that made patients wait for Excellus' response before scheduling exams like PET scans, CT scans and MRIs.

The agreement drops the number of tests requiring approval from 252 to 125, and exempts all CT exams for cancer patients.

After contracting with CareCore National of Wappingers Falls, N.Y., in October 2007 to handle referrals for diagnostic imaging, Excellus launched a program that required doctors to obtain the payor’s approval for hundreds of exams.

Doctors and patient advocacy groups issued complaints with N.Y. Attorney General Andrew Cuomo’s office and protested Excellus’ method of cutting reimbursements the number of radiology procedures.

Jamie Kerr, MD, Excellus’ vice president and chief medical officer for utilization and management, said the decision was meant to cut rising costs, drive down the number of superfluous tests and eliminate unnecessary exposure to radiology.

The new plan, which takes effect July 23, will require that Excellus disclose its criteria for approving tests and make decisions on urgent requests within three hours. The payor will also waive the approval requirements for some physicians who frequently order certain exams and issue approval on all tests within 180 days for patients with certain conditions.