Big HMO to File Suit Against Review Panel : Health care: Blue Cross’ CaliforniaCare, which was denied accreditation, claims the assessment of its performance was flawed.

After failing a key medical quality review, a Blue Cross of California subsidiary planned to file a lawsuit today against a well-regarded national accrediting group, claiming that the review was flawed.

CaliforniaCare Health Plans, one of the state’s largest health maintenance organizations, said late Thursday that it would file the civil suit against the National Committee for Quality Assurance in federal court in Washington. The NCQA, based there, recently denied accreditation to the Woodland Hills-based HMO.

The NCQA “failed to follow its own rules and procedures” and “to afford fair and due process,” CaliforniaCare said in a statement.

CaliforniaCare’s court action is an unusually aggressive move against an independent accreditation organization that was created by the managed health care industry and employer groups. NCQA accreditation is a voluntary process.

Since its inception several years ago, the NCQA accreditation has quickly become akin to the Good Housekeeping Seal of Approval for HMOs. Health plans now cite the NCQA approval in their marketing pitches to employers and individuals, and in rebutting criticism that they provide a lesser standard of care than traditional health plans.

Jeffrey Rideout, CaliforniaCare medical director, said the NCQA survey “did not find any deficiencies in the quality of medical care delivered to enrollees.” Instead, the group’s review focused on “compliance with procedural standards.”

Rideout said most California HMOs contract with physician groups to provide medical care and that the NCQA process does not measure the quality of care provided by those groups. “The physicians provide the health care, not the health plans, so our role is to bring consistency and quality improvement across our networks,” he said.

Barry Scholl, an NCQA spokesman, declined to comment on the CaliforniaCare suit. The group does not make public the details of a health plan’s review.

The CaliforniaCare suit will ask the court to prohibit NCQA from implementing its accreditation decision or publishing it in any form. It also seeks unspecified damages.

The NCQA has 50 criteria for rating health plans, including quality improvement, members’ rights and preventive health programs. The group has denied accreditation to just 13% of 191 HMOs it has reviewed.

For CaliforniaCare, which has 834,000 members, the NCQA denial poses a big public relations problem. It comes at a time of year when many employers are choosing health plans during “open enrollment” periods.

Some observers said the lack of accreditation might harm CaliforniaCare’s reputation with employers who view NCQA approval as the best available measure of an HMO’s quality.

Tom Fischer, health division chief for the California Public Employees Retirement System, said lack of accreditation would be a concern but would not disqualify an HMO from contracting with the giant state pension fund.

It also comes just weeks before CaliforniaCare’s parent company, WellPoint Health Networks, is expected to complete a $1.8-billion merger with Health Systems International, which operates the Health Net HMO.