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Blue Cross Denied Coverage

Posted by Cynthia D on 4/05/01 at 20:14 (043762)

Well the jury is in. Blue Cross Choice officially denied my claim to cover ESWT, I quote 'We cannot pay this claim because this particular service is not covered under your contract. Please check your plan materials for clarification of your coverage.'

Can't say I'm surprised at all. I usually find that whoever receives the first claim always automatically looks for a reason to reject it so I will look into persuing this and will keep you posted. Has anyone had Blue Cross pay for ESWT, I remember someone saying something about making a claim there. Thanks.

Re: Blue Cross Denied Coverage

Dr. Zuckerman on 4/05/01 at 20:26 (043766)

We have found that in New Jersey the Blue Shields still consider any ESWT whether it be the ossatron, orbasone or any zone to be investigational treatment until there is peer review literature . The fact that there is FDA approval for plantar fasciitis doesn't seem to help in the state of New Jersey. I have spoke to many Medical Director thru out the country and this still seems to be the common answer when denying ESWT claims. I have even showed the textbook for Shockwave Therapy. I have even showe them FDA studies for the ossatron. The machine didn't make any difference.

I even told them I knew Pauline from heelspurs.com .

Re: Blue Cross Denied Coverage

Camilla on 4/05/01 at 21:03 (043773)

Cynthia,

Don't stop there. I was told by Mercy HMO that 300 other insured in 2001 have requested pre-cert for EWST and all have been denied. All insurance contracts have an appeal provision. DO IT. Make your next call to the Department of Insurance, in the state where you live, request a complaint form. The state where you live doesn't know that care is being denied if you don't tell them. If they receive enough complaints, they will inquire into the denial of services.

Hope this helps.

Camilla

Re: Blue Cross Denied Coverage

Beverly on 4/05/01 at 21:14 (043778)

Cynthia,

This is bad news to me too. I'm on Blue Cross Choice also. I'm already psyching myself out for having to pay for EWST out-of-pocket. I wonder how long it will take them to do that peer review?

Keep on pushing. The more of us who do, the more likely it will eventually get covered.

I'm going to 'just do it' sometime this summer. I'll feel very lucky if insurance co. have started paying by then, but I'm not getting my hopes up too high.
Beverly

Re: Blue Cross Denied Coverage

Barbara TX on 4/06/01 at 12:14 (043826)

I am shocked that not even the 'Pauline factor' made a difference in Blue Cross coverage. They should be ashamed of themselves! Perhaps we should sent Pauline over personally to break a few kneecaps!

United Health also does not cover the procedcure due to lack of peer-reviewed literature. It doesn't matter if you show them the literature... they will simply say there is a lack. Still, if you do want ESWT - keep calling the insurance companies. Perhaps the sheer number of requests will make a difference? B.

Re: Blue Cross Denied Coverage

BrianG on 4/06/01 at 12:15 (043827)

Hi Cynthia,

If you have the time, I suggest you file an appeal. You only have a certain number of days to file, maybe 60? In my own case, I wanted an MRI, of one heel, from my HMO. They denied me, and I took it all the way to the final appeals board. I won, I got the MRI. Just be prepared when you go in. I had a prepared statement, because I didn't want to forget anything. I asked if I could read the statement, and they had no problem with it. I wish you luck.

BCG

Re: Blue Cross Denied Coverage

Richard Perez, DPM on 4/06/01 at hrmin (043847)

If, after exhausting the appeals process with your insurance carrier and they continue to deny coverage, you always have the right to file a complaint with your State Insurance Commissioner's Office. Insurance companies take these complaints very seriously. This may help them change their classification of ESWT as 'experimental.'
Richard Perez, DPM

Re: Blue Cross Denied Coverage

Dr. Zuckerman on 4/06/01 at 16:05 (043853)

In our state the commission won't get involved with fee disputes. It usually is a ring around the rosie. My idea is to sue them in small claims court. Insurance companies in my state have to pay for any service that is reasonable and has a medical indication.

Re: Blue Cross Denied Coverage

Richard Perez, DPM on 4/06/01 at hrmin (043883)

I agree that the State Insurance agency will not help with fee disputes, but, as a general rule, carriers do not like having complaints lodged against them. If enough complain, insurance companies may change their classification of ESWT as experimental. Almost all patient's plans have exclusion clauses for experimental procedures. It may not help in the short term, but down the road it may help things change.
Richard Perez, DPM

Re: Blue Cross Denied Coverage

Cynthia D on 4/07/01 at 08:47 (043902)

Thanks for all your input. I will persue this, if not to help myself, to help future suffers who need this treatment. I will keep you posted. I guess I'll start with a appeal. I may contact you, Dr. Z. for some ammunition. Dr. Ried, if I end up needing it, I wonder if your BCBS patient would mind sharing her files with me? Thanks. BTW, my reply button doesn't work either. I usually find where I want to respond to a post, and if the 'reply' button doesn't work, I go back to the thread and click on the original message (not the view thread button), I them am able to reply and to keep my reply in the thread. It's fast for me because I have a high speed dsl line, but still a pain. Just a suggestion.

Re: It would be very helpful to have a list of insurance companies that pay for ESWT

Dr. Zuckerman on 4/08/01 at 11:22 (043974)

Hi,

I have asked this in the past but hopefully you can get this Cynthia.

If we have real copies of payment sent along with the appeal, this would help alot. This is how I use to handle insurance companies that told me years ago that my fee was above the UCR levels. I use to mail in the copy from three or four insurances that paid that specific amount and a copy to the patient and sure enough the insurance paid.

Insurance companies hate to see the other companies( their competition)
with better fee schedules or in this case payment for ESWT.

If would be great for a section on this board to show what insurance companies are paying and how much.

Re: It would be very helpful to have a list of insurance companies that pay for ESWT

Cynthia D on 4/08/01 at 11:42 (043980)

OK good idea, I'll start a new thread.

Re: It would be very helpful to have a list of insurance companies that pay for ESWT

Kate on 4/08/01 at 21:18 (044036)

Dr.Z,
Don't forget about Boiler makers union. They paid 80%.

Re: To Barbara TX Blue Cross Denied Coverage

Pauline on 4/13/01 at 23:08 (044520)

Strictly for Barbara TX, Your reference to me in your posting is certainly uncalled for.

On the subject, however, the insurance companies could be waiting for larger centers to get involved. It's quite possible that if locations like Massachusetts General, Emory, Henry Ford, John Hopkins, Stanford etc come on line with ESWT insurance companies may look at ESWT in a different light. Anything is possible.

Re: To Barbara TX Blue Cross Denied Coverage

Pauline on 4/14/01 at 09:40 (044558)

Barbara,
It wasn't so long ago that you asked me to put you on my prayer list, I haven't received any notification to the contrary. Your still there!
Happy Easter.

Re: Blue Cross Denied Coverage

Dr. Zuckerman on 4/05/01 at 20:26 (043766)

We have found that in New Jersey the Blue Shields still consider any ESWT whether it be the ossatron, orbasone or any zone to be investigational treatment until there is peer review literature . The fact that there is FDA approval for plantar fasciitis doesn't seem to help in the state of New Jersey. I have spoke to many Medical Director thru out the country and this still seems to be the common answer when denying ESWT claims. I have even showed the textbook for Shockwave Therapy. I have even showe them FDA studies for the ossatron. The machine didn't make any difference.

I even told them I knew Pauline from heelspurs.com .

Re: Blue Cross Denied Coverage

Camilla on 4/05/01 at 21:03 (043773)

Cynthia,

Don't stop there. I was told by Mercy HMO that 300 other insured in 2001 have requested pre-cert for EWST and all have been denied. All insurance contracts have an appeal provision. DO IT. Make your next call to the Department of Insurance, in the state where you live, request a complaint form. The state where you live doesn't know that care is being denied if you don't tell them. If they receive enough complaints, they will inquire into the denial of services.

Hope this helps.

Camilla

Re: Blue Cross Denied Coverage

Beverly on 4/05/01 at 21:14 (043778)

Cynthia,

This is bad news to me too. I'm on Blue Cross Choice also. I'm already psyching myself out for having to pay for EWST out-of-pocket. I wonder how long it will take them to do that peer review?

Keep on pushing. The more of us who do, the more likely it will eventually get covered.

I'm going to 'just do it' sometime this summer. I'll feel very lucky if insurance co. have started paying by then, but I'm not getting my hopes up too high.
Beverly

Re: Blue Cross Denied Coverage

Barbara TX on 4/06/01 at 12:14 (043826)

I am shocked that not even the 'Pauline factor' made a difference in Blue Cross coverage. They should be ashamed of themselves! Perhaps we should sent Pauline over personally to break a few kneecaps!

United Health also does not cover the procedcure due to lack of peer-reviewed literature. It doesn't matter if you show them the literature... they will simply say there is a lack. Still, if you do want ESWT - keep calling the insurance companies. Perhaps the sheer number of requests will make a difference? B.

Re: Blue Cross Denied Coverage

BrianG on 4/06/01 at 12:15 (043827)

Hi Cynthia,

If you have the time, I suggest you file an appeal. You only have a certain number of days to file, maybe 60? In my own case, I wanted an MRI, of one heel, from my HMO. They denied me, and I took it all the way to the final appeals board. I won, I got the MRI. Just be prepared when you go in. I had a prepared statement, because I didn't want to forget anything. I asked if I could read the statement, and they had no problem with it. I wish you luck.

BCG

Re: Blue Cross Denied Coverage

Richard Perez, DPM on 4/06/01 at hrmin (043847)

If, after exhausting the appeals process with your insurance carrier and they continue to deny coverage, you always have the right to file a complaint with your State Insurance Commissioner's Office. Insurance companies take these complaints very seriously. This may help them change their classification of ESWT as 'experimental.'
Richard Perez, DPM

Re: Blue Cross Denied Coverage

Dr. Zuckerman on 4/06/01 at 16:05 (043853)

In our state the commission won't get involved with fee disputes. It usually is a ring around the rosie. My idea is to sue them in small claims court. Insurance companies in my state have to pay for any service that is reasonable and has a medical indication.

Re: Blue Cross Denied Coverage

Richard Perez, DPM on 4/06/01 at hrmin (043883)

I agree that the State Insurance agency will not help with fee disputes, but, as a general rule, carriers do not like having complaints lodged against them. If enough complain, insurance companies may change their classification of ESWT as experimental. Almost all patient's plans have exclusion clauses for experimental procedures. It may not help in the short term, but down the road it may help things change.
Richard Perez, DPM

Re: Blue Cross Denied Coverage

Cynthia D on 4/07/01 at 08:47 (043902)

Thanks for all your input. I will persue this, if not to help myself, to help future suffers who need this treatment. I will keep you posted. I guess I'll start with a appeal. I may contact you, Dr. Z. for some ammunition. Dr. Ried, if I end up needing it, I wonder if your BCBS patient would mind sharing her files with me? Thanks. BTW, my reply button doesn't work either. I usually find where I want to respond to a post, and if the 'reply' button doesn't work, I go back to the thread and click on the original message (not the view thread button), I them am able to reply and to keep my reply in the thread. It's fast for me because I have a high speed dsl line, but still a pain. Just a suggestion.

Re: It would be very helpful to have a list of insurance companies that pay for ESWT

Dr. Zuckerman on 4/08/01 at 11:22 (043974)

Hi,

I have asked this in the past but hopefully you can get this Cynthia.

If we have real copies of payment sent along with the appeal, this would help alot. This is how I use to handle insurance companies that told me years ago that my fee was above the UCR levels. I use to mail in the copy from three or four insurances that paid that specific amount and a copy to the patient and sure enough the insurance paid.

Insurance companies hate to see the other companies( their competition)
with better fee schedules or in this case payment for ESWT.

If would be great for a section on this board to show what insurance companies are paying and how much.

Re: It would be very helpful to have a list of insurance companies that pay for ESWT

Cynthia D on 4/08/01 at 11:42 (043980)

OK good idea, I'll start a new thread.

Re: It would be very helpful to have a list of insurance companies that pay for ESWT

Kate on 4/08/01 at 21:18 (044036)

Dr.Z,
Don't forget about Boiler makers union. They paid 80%.

Re: To Barbara TX Blue Cross Denied Coverage

Pauline on 4/13/01 at 23:08 (044520)

Strictly for Barbara TX, Your reference to me in your posting is certainly uncalled for.

On the subject, however, the insurance companies could be waiting for larger centers to get involved. It's quite possible that if locations like Massachusetts General, Emory, Henry Ford, John Hopkins, Stanford etc come on line with ESWT insurance companies may look at ESWT in a different light. Anything is possible.

Re: To Barbara TX Blue Cross Denied Coverage

Pauline on 4/14/01 at 09:40 (044558)

Barbara,
It wasn't so long ago that you asked me to put you on my prayer list, I haven't received any notification to the contrary. Your still there!
Happy Easter.