Reimbursement: A Look Inside the Black Box

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Reimbursement A Look Inside the Black Box

• Eric L. Book, MD
• March 27, 2008

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BSC Technology Assessment

• California Technology Assessment Forum (CTAF) -
  Public forum sponsored by the Blue Shield of
  California Foundation to assess new technologies
• www.ctaf.org
• Blue Cross Blue Shield Association (BCBSA)
  Technology Assessment Center (TEC)
• Blue Shield of California utilizes information
  recommendations and guidelines from CTAF and TEC
  for incorporation into Medical Policy

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Technology Assessment Criteria

• The technology must have final approval from the
  appropriate government regulatory bodies.
• The scientific evidence must permit conclusions
  concerning the effectiveness of the technology
  regarding health outcomes.
• Evidence should consist of well designed and
  well conducted investigations published in
  peer-reviewed journals. The quality of the body
  of studies and the consistency of the results are
  considered in evaluating the evidence.

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Technology Assessment Criteria

• 3.The technology must improve the net health
  outcomes.
• The technologys beneficial effects on health
  outcomes should outweigh any harmful effects on
  health outcomes.
• For diagnostic tests, there is evidence that use
  of the test would result in improved medical
  management in a way that will benefit the
  patient.
• 4. The technology must be as beneficial as any
  established alternatives.
• The technology should improve the net health
  outcomes as much as or more than established
  alternatives.

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Technology Assessment Criteria

• 5.The improvement must be attainable outside the
  investigational settings.
• When used under the usual conditions of medical
  practice, the technology should be reasonably
  expected to satisfy Criteria No. 3 and No. 4.
• These criteria determine whether medical devices
  or treatments are investigational or not. Blue
  Shield of California then determines coverage
  based on contract language and medical necessity.

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BSC Coverage Determination

• The medical device must comply with contract
  language and be considered medically necessary in
  order to become a covered benefit
• For Example Stool gene testing for colon cancer
  was determined to meet CTAF criteria. It has
  comparable sensitivity and specificity to fecal
  occult blood testing and is significantly more
  expensive.
• However, BSC contract language requires screening
  tests to be approved by the United States
  Preventive Services Task Force and stool gene
  testing has not been approved by USPSTF
• Stool gene testing is not a BSC covered benefit

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Medical Necessity

• Example of value language.
• If there are two or more Medically Necessary
  services that may be provided for the illness,
  injury or medical condition, Blue Shield will
  provide benefits based on the most cost-effective
  service.

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CMS Conflicts

• Periodically and infrequently the Center for
  Medicare/Medicaid Services approves coverage for
  a device/procedure that BSC considers
  investigational. Most of the time BSC maintains
  its position
• Example
• PET Scanning for Alzheimers Disease CTAF has
  determined that this test is not good at
  determining causes of dementiaBSC does not
  provide coverage

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