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ESWT and Blue Cross Blue Shield

Posted by Teresa W on 8/20/03 at 15:46 (127423)

Please leave a message if a Blue Cross/Blue Shield provider has covered this non-invasive surgery for you. I need all the cases I can find for my appeal to the insurance carrier for coverage. (name, place, date, hospital and/or physician) Thanks.

Re: ESWT and Blue Cross Blue Shield

Scott D. on 8/20/03 at 16:13 (127427)

Teresa,

There are BCBS providers throughout the country that cover ESWT. The standard answer from them in a case like this is that they are all independent of each other though in deciding what they will cover. Here's a little ammo for you, good luck!

http://www.bcbsnc.com/services/medical-policy/pdf/lithotripsy_extracorporeal_for_orthopedic_problems.pdf

Re: ESWT and Blue Cross Blue Shield

Peter R on 8/20/03 at 17:45 (127445)

Excellus Health Plan, BCBS Utica, Rochester New York area considers ESWT Investigational and doen not cover it.

Re: ESWT and Blue Cross Blue Shield

Ed Davis, DPM on 8/20/03 at 19:37 (127468)

Peter:

One of the difficulties with BC/BS is a decision by their national 'tech' committee earlier this year. They looked at the scores of studies supporting ESWT and then looked at the flawed Buchbinder study and concluded that the evidence supporting ESWT was equivocal.(talk about a political decision by a group pretending to base decisions on science)
The various BC/BS plans are not obligated to follow the tech committee recommendations but it is my understanding that the recommendations of the tech committee carries a lot of weight with the plans.
Ed

Re: ESWT and Blue Cross Blue Shield

Dr. Z on 8/20/03 at 20:07 (127477)

I agree. The insurance companies must have a will and a back bone to step up to the plate to do the right thing. If they don't want to cover ESWT at least cover a portion of this treatment. Lets say one thousand dollars

Re: ESWT and Blue Cross Blue Shield

Ed Davis, DPM on 8/21/03 at 14:17 (127552)

Dr. Z:
Yes. Some type of tiered coverage is the way to provide comprehensive coverage while maintaining control over costs. Tiered coverage is a win-win situation for all parties involved in the process.
Ed

Re: ESWT and Blue Cross Blue Shield

Dr. Z on 8/21/03 at 15:20 (127556)

I believe that is what is done with most dental work. So the patient could pay a portion and the insurance would pay a portion. Now all we have to do is sell this to the insurance companies. I think I will start to work on this tommorrow.

Re: ESWT and Blue Cross Blue Shield

Rick T on 8/21/03 at 17:51 (127581)

My doctor recommended ESWT for my PF, and BC/BS of Indiana turned me down. I fired off a letter of appeal to my National Benefit Center and used the link to the North Carolina BC/BS site for ammo. Ironically, if I worked in North Carolina I would qualify... If anyone else using this message board can find any more inconsistencies in BC/BS policy toward ESWT post them here.

Re: ESWT and Blue Cross Blue Shield

Scott D. on 8/21/03 at 17:58 (127582)

Dr. Z,

I think that is a very dangerous road to go down with the insurance companies. Many will do doubt jump at the chance to pay a limited portion of the fees and be off the hook. The problem is that a year from now they will reduce that fee, and then reduce it farther as time goes on. Look what has happened with your reimbursements for other codes over time.

The thing to convince them of is that ESWT is the standard of care. Once that point is made they will be obligated to cover the costs. The same was absolutely true in the early days of lithotripsy. It seemed like it took us forever to get the insurance companies to agree that ESWL was the standard of care for kidney stones, but eventually they had no choice but to approve treatments. I had a small company just last year deny a claim for ESWL because they called it investigational! After a conversation with their medical director he quickly changed their position on paying for ESWL. Had we offered them an out to cover only a portion of the costs when they were trying to decide what to do, think of all of the additional costs that would be borne by the patients, now instead of the always for profit mega-corporations that will forever try to hold onto every last dollar possible.

Progress is slow but we have to look at the long term picture and the financial consequences to our patients of the future. We've gotten the local BCBS carrier to agree to pay for treatments after a year-long negotiation. We've also, contrary to what Peter states in an above post, been paid by Excellus BCBS for a treatment. It takes time and it takes a heck of a lot of effort! Be patient, do the leg work, make all the calls, do all the follow-ups and the letter writing, and eventually it will work out. We have a very good treatment to offer, let's not act like we will settle and time will prove us right.

Re: ESWT and Blue Cross Blue Shield

Dr. Z on 8/21/03 at 19:24 (127585)

I agree 100% that we do have a great treatment and that it will, if it isn't already the standard of care.
I do have a question. If we look at demographics for kidney stones that require ESWL do you know what it is. I know what is is for chronic pf.

Re: ESWT and Blue Cross Blue Shield

Scott D. on 8/21/03 at 19:47 (127592)

Dr. Z,

Convincing the insurance companies that it's the standard of care is the tricky and time consuming part.

The standard demographic for kidney stones was always that the majority were men, aged 40-60. Our experience in over 10,000 treatments is almost exactly 50/50 male/female and 35-70 years of age being the majority of cases. We have treated patients ranging from 13 months (over 100 pediatric cases) to 93 years of age.

Re: ESWT and Blue Cross Blue Shield

Ed Davis, DPM on 8/21/03 at 20:11 (127593)

Dr. Z:

I am working hard to drive home the point to 3rd parties that ESWT indeed is the standard of care. The important thing now is for colleagues to back us up on that issue. A position paper from one of our organizations (don't hold your breath) would be very helpful in furthering this goal.

Reimbursement levels have declined but that is more of a problem when providers are forced via contract to accept a specific level as opposed to when a third party offers a fixed benefit level for a service so I cannot agree with Scott on that issue.
Ed

Re: ESWT and Blue Cross Blue Shield

Dr. Z on 8/21/03 at 20:39 (127597)

Ed,

There is a position paper by the APMA that is going to be published very soon. Will it help ??
I do like the idea of universal coverage at lets say $1500 dollars and the patient has to pay the rest of the bill. If this would expand coverage I would agree to this. I am not that ESWL is the same as ESWT . Do you know the demographics of ESWL?

Re: ESWT and Blue Cross Blue Shield

Dr. Z on 8/21/03 at 20:44 (127598)

Sorry,

Here is what I meant. How many patients in one year will need ESWL. For ESWT just in the Philadelphia area it is 16,000 cases that are chronic and are good cases for ESWT

Re: ESWT and Blue Cross Blue Shield

Ed Davis, DPM on 8/21/03 at 21:22 (127600)

Dr. Z:
I have not heard anything about the APMA position paper. ACFAS came out with guidelines for treatment of PF a couple of years ago but the quality of that paper was not very good -- unusual for one of their publications.
I am not familiar with the demographics of ESWL but assume that Scott could answer that.

Ed

Re: ESWT and Blue Cross Blue Shield

Dr. Z on 8/21/03 at 21:48 (127603)

I have it . Give me your fax number. There are minor problems with the paper but I believe the APMA is going to fix it. Over all not bad. Its title is APMA POLICY ON ESWT.

Re: ESWT and Blue Cross Blue Shield

Ed Davis, DPM on 8/21/03 at 23:34 (127616)

Dr. Z:
My fax number is 253-841-0878. Looking forward to seeing it.
Ed

Re: ESWT and Blue Cross Blue Shield

Scott D. on 8/22/03 at 09:04 (127637)

Dr. Z,

I'm sorry but I don't know those numbers for my area, let alone for Philly. Is there a reason you were wondering what they are?

Re: ESWT and Blue Cross Blue Shield

Scott D. on 8/22/03 at 09:08 (127638)

Ed,

What is the difference is between having a 'contract to accept a specific level' and the insurer offering a 'fixed benefit level'?

Re: ESWT and Blue Cross Blue Shield

Dr. Z on 8/22/03 at 09:41 (127645)

I faxed over 15 pages which include my comments to the APMA. This WAS already sent out to all insurance companies. If you want to talk about it give me a call at 1-856-848-3338 or e-mail me at (email removed)

Re: ESWT and Blue Cross Blue Shield

Ed Davis, DPM on 8/22/03 at 10:46 (127654)

Scott:

Insurance contracts, for the most part, specify the allowable amount for a service and then pay some percentage of that amount. Medicare, for example, specifies an allowable amount and then pays 80% of that amount to the provider. The provider, by contract (or by government edict in the case of Medicare)can charge the difference between the amount paid and amount allowed to the patient but cannot charge the patient more than the allowed amount.

The current situation is that third parties have steadily decreased the allowed amount on a number of services. As such, they are paying the same fixed percentage of that allowed amount (but it is the same percentage of a smaller amount). The patient does not have to make up the difference.

In contrast, if a third party has a fixed benefit for a particular service, they are paying the same dollar amount for a service irrespective of the provider's fee. That situation does not lock the provider in to a specific ceiling (allowable charge).

For example, Regence Blue Shield in WA has generally covered orthotics. Depending on the contract they pay from 80 to 100% of the amount they allow. That allowable amount has decreased from approximately $400 to about $270 over the years. Blue Cross of WA, has generally only covered orthotics in their preventative medicine benefit. They allow a fixed amount of $200 that patients can apply to orthotics but the provider sets the fee for the orthotics. At first glance, it would appear that the Regence policy is more favorable to patients. At the $270 level, providers cannot regualrly use a first tier lab for orthotics so those patients are locked into not getting top quality orthotics. With the Blue Cross situation, providers are free to order from first tier labs since the charge can be passed through via no limit on the patient charge.
Ed

Re: ESWT and Blue Cross Blue Shield

Dr. Z on 8/22/03 at 11:02 (127656)

This is how they do it with Dental procedures . A fixed amount period per policy. The patient pays the difference and or negotiates a fee with the provider

Re: ESWT and Blue Cross Blue Shield

Scott D. on 8/22/03 at 11:51 (127663)

Ed,

Thanks for the follow-up. We don't have a single contract that is based on a fixed percentage of some variable number, all of our contracts would be considered fixed amounts.

Re: ESWT and Blue Cross Blue Shield

Dr. Z on 8/22/03 at 13:51 (127677)

Yes. I was wondering if the insurance companies are comparing the potential amount ESWL procedures with ESWT procedures per year. The insurance Companies may or may not be thinking that if they start to under write universal ESWT coverage then they will have to pay x amount of dollars using the ESWL as a payment model. Just thinking out loud

Re: ESWT and Blue Cross Blue Shield

Ed Davis, DPM on 8/22/03 at 14:35 (127682)

Scott:
Do those fixed amounts relate to a percentage of an allowable charge or are those amounts a fixed benefit allowing you and the patient to negotiate the balance?
Ed

Re: ESWT and Blue Cross Blue Shield

Ed Davis, DPM on 8/22/03 at 14:38 (127684)

Dr. Z:
Thanks for the fax. Had 4 emergency patients today so I cannot look at it until tonight.

I prefer the dental model for physician reimbursement. It allows a freer market and hopefully, a situation where insurers are not trying to control everything.
Ed

Re: ESWT and Blue Cross Blue Shield

Peter R on 8/22/03 at 14:49 (127685)

Posted by Peter R on 8/20/03 at 17:45 View Thread
Excellus Health Plan, BCBS Utica, Rochester New York area considers ESWT Investigational and does not cover it

Re: ESWT and Blue Cross Blue Shield

Ed Davis, DPM on 8/22/03 at 15:20 (127691)

Peter:
Calling something 'investigational' is just an excuse not to cover something.
Ed

Re: ESWT and Blue Cross Blue Shield

Scott D. on 8/22/03 at 15:45 (127699)

Ed,

It's simply a fixed amount, no negotiations with the patients are needed.

Re: ESWT and Blue Cross Blue Shield

Teresa W on 8/22/03 at 21:39 (127737)

Scott- Which state are you from in which Excellus BC/BS made a payment for ESWT??

Re: ESWT and Blue Cross Blue Shield

Dr. Z on 8/22/03 at 22:50 (127741)

He is in New York. What state is Excellus in ? Payment is determined by the local carrier which in this case is New York Empire Blue Shield

Re: ESWT and Blue Cross Blue Shield

Peter R on 8/24/03 at 08:34 (127801)

Excellus Health Planis in upstate NY- Utica and Rochester area Policy # 2.01.31 states that 'there is insufficient data to draw conclusions about the effectiveness of ESWT for the treatment of musculoskeletal conditions' But they also state that 'elibility for reimbursement is based upon the benefits set forth in the member's subsciber contract.'

Re: ESWT and Blue Cross Blue Shield

Scott D. on 8/24/03 at 09:38 (127805)

Teresa,

As Dr. Z. said, we are in NY.

Re: ESWT and Blue Cross Blue Shield

Ed Davis,DPM on 8/25/03 at 09:40 (127898)

Peter and Dr. Z:
I have actually ran into a situation in which I had treated a patient with Blue coverage from a part of the country in which ESWT was covered. Per that person's contract, the claim was turned over to the local Blue carrier in WA which does not cover ESWT (provisionally) and the claim was rejected.
Ed

Re: ESWT and Blue Cross Blue Shield

Teresa W on 8/25/03 at 16:46 (127948)

I am also in NYS with BC/BS. Excellus is the local name associated with BC/BS. Without breaking confidentiality, I'd be very interested in how and when and why he got payment for that treatment and yet I am being denied. Did he have to go through an internal or external appeal process? Any information you can share would be great, or I can give you my podiatrist's name and fax number if you could share info that way. Thanks.