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Note to Dr. Davis

Posted by SteveG on 5/13/03 at 20:56 (118624)

Dr. Davis - I just received a letter from Regence telling me that they are denying authorization
for the treatment I had on May 1st. If I had known that they were not going to pay for the treatment, I would have got another round of low energy or made the trip to Canada. We need to appeal this ASAP. I will call Regence tomorrow to see of the claim has already been denied. If there is anything I need to do help with the appeal, let me know.

-thanks

Re: Note to Dr. Davis

Ed Davis, DPM on 5/14/03 at 14:56 (118733)

Steve:
It was my understanding that we had approval from Regence previously. Regence' approval process is in turmoil and we are constantly getting reversals of decisions and decisions inconsistent with their own stated policies on a number of issues. I have had numerous occasions in which they approved the service, paid the bill and then took the money back, reversing their decsion to authorize and pay several months later. They post their policies including the ESWT policy on their website: http://www.regence.wa.org We will certainly appeal this.

I would encourage you to write a letter of appeal in addition with a cc to the state insurance commissioner. I think that only once they have recieved enough inquiries from the insurance commissioner will they clean up their approval/authorization process.
Ed

Re: Note to Dr. Davis - correction

Ed Davis, DPM on 5/14/03 at 15:02 (118735)

http://www.wa.regence.com

Re: Note to Dr. Davis

SteveG on 5/14/03 at 15:59 (118756)

Ed - I talked to the folks at Regence today and they gave me a song and dance about how the treatment was investigational and that I got approval for a different machine and a different doctor - this must be referring to my first authorization with Dr. Labaron. They also told me that the machine we used does not have FDA approval? That can't be right since it was the Dornier. At any rate, I started the approval process and they will told me I will be 'notified'. I hope this does not mean that they will make a decision without our input. I will, as you say, write a letter to the insurance commissioner - this is madness. If there is any information I need to provide to help the appeal at your end, just let me know.

-thanks

Re: For Steve

Sharon W on 5/14/03 at 17:15 (118761)

Steve,

I just saw this -- that really BITES!

Good luck with the appeal.

Sharon
%%-

Re: For Steve

Ed Davis, DPM on 5/14/03 at 21:18 (118780)

Sharon:
It sort of goes with the territory. Battling insurance companies to get claims paid is par for the course. It is a massive waste of time and money that could be better spent treating patients.
Ed

Re: Note to Dr. Davis

Ed Davis, DPM on 5/14/03 at 21:27 (118781)

Steve:
Regence is the only insurer in WA State that tries to dictate which machine is used. We used the Dornier because they claim that they cover use of that machine. The different doctor issue is irrelevant becasue we are Regence providers and many providers are in groups anyway. I am confident that they will get it straight eventually but I still encourage a letter to the insurance commissioner so that a complaint is logged and so that Regence must answer the insurance commmisioner -- that forces a review on the part of Regence. Sorry for the hassles but wrestling with insurance companies is a major part of my office's work load and unfortunately a major part of medical care nowadays. The one way to avoid insurance company hassles is to do surgery -- the path of least resistance -- one of the reasons that there is still much plantar fascial release surgery being done.
Ed

Re: Note to Dr. Davis

SteveG on 5/15/03 at 11:01 (118844)

Ed - My wife works at Regence and notes, as you did, that the policy on their web site states that ESWT is covered. She tells me that they are planning on declaring the treatment investigational in a few months and cite the JAMA article as the rationale. However, since this is in the future, they should have authorized my treatment - especially since it was done with the Dornier and you are a Regence provider. I gather from reading the letter from Regence, and talking to my wife, that you are also, as the treating physician, going to file an appeal that is separate from the letter my wife and I are working on. Is this the approach we are going to take?

Re: For Steve

SteveG on 5/15/03 at 11:56 (118850)

Thanks, Sharon - I fully intend to fight the good fight

Re: For Steve

Sharon W on 5/15/03 at 12:55 (118854)

Go for it!! Don't let those insurance weasels get by with not paying for this!

Sharon!
:((

Re: Note to Dr. Davis

Ed Davis, DPM on 5/15/03 at 18:58 (118914)

Steve:
We will file a letter of appeal but did not get a letter of rejection yet and generally wait for that. Send us a copy of yours so we can respond accordingly.

WA Dept. of L&I recently stopped covering ESWT on the same rationale. The JAMA article is the ONLY article that went against ESWT. It is badly flawed and Rompe, in his recent article (supplied by Elliot who posts here) has a good critique of that article. Use of such an article would be little more than a pretext since scores of higher quality articles support the use of ESWT.

While the vast majority of evidence supports ESWT, even more evidence goes against surgery. How can Regence state that they are acting on the evidence? This is why I would encourage that patients involve the insurance commissioner.
Ed

Re: A better way...

Ed Davis, DPM on 5/15/03 at 19:06 (118916)

Steve:
I have long encourage Regence to have coverage tiers. Regence recently removed a number of drugs from their formulary. Blue Cross covers virtually all drugs but has 3 tiers of coverage, paying the highest percentage for 'preferred' drugs. There are some very important drugs that Regence refuses to pay for. The use of tiers in both drug and other types of coverage would provide Regence's insured with the opportunity to have more treatment choices and have the advantage of contractural prices guarantees. When an item is completely removed from coverage, it is off contract, and thus no price protection exists.
Ed