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need advice from dr's insurance refusing to pay for ESWT

Posted by David B on 10/11/03 at 19:42 (133662)

Before I had my shock wave treatment done I told my doctor to check with the insurance company to see if they would cover it, if they would not pay I would not have the procedure done because I cant afford $5400. You see my doctor had a 3nd party come in and do the procedure they were the ones that owned the dornier, they told the doctor yeah healthlink will pay. I THOUGHT they got it preapproved and there would not be any problems, obviously they just assumed healthlink would pay. Today, I got a letter from my insurance company saying they WILL NOT pay for ESWT because it is so new to the medical field and is not proven it will fix PF long term. What can I do? I am thinking about calling my doctor on monday and give him a piece of my mind and tell him they were the ones that told me it was covered and if you want your money then YOU take it up with the insurance cause im not paying one dime! I would have NEVER had ESWT done if they said they would not pay. If it comes down to them either sueing me I will just tell them I will pay them $10 a month until I have it paid for, they can't make me pay them it all at once can they?? Im not very happy with my doctor at all. Please give me some advice.

Re: need advice from dr's insurance refusing to pay for ESWT

Dr. Z on 10/11/03 at 20:01 (133664)

Lets get some additional information first. Did your doctor get what is called a pre-determination letter with your health plan? This is a in writing determination that your health insurance will pay for ESWT. Even if they received this pre-determination you need to find out in writing if your specific policy has ESWT as a benefit.
They may have this information and all that is needed to get Healtlink to re-consider coverage.

Now on another note. Did you sign a formed called an assigment of benefits which may or may not have a clause which states if your insurance company doesn't pay this claim you will pay for it.?

I would hope that the company that supplied the dornier equipment would have pre-certified your procedure, but then again who knows. What was the name of the company that supplied the dornier. Where do you live?.

So get some additional information and then we can talk. Ok

Re: need advice from dr's insurance refusing to pay for ESWT

David B on 10/11/03 at 20:12 (133668)

Dr. Z I did not sign any papers. Im beginning to think the company that my doctor hired is a fly by nite company. The name of the company was Orthowave they are out of St. Louis MO and my doctor is in columbia mo. Orthowave told my doctor yeah healthlink will pay, I have no idea if they actually checked into it or not, (they charged $3800 for there services). This company only has like 3 people working for them a couple of people that take the machine around to different offices and a secretary. Whats my legal rights?

Re: need advice from dr's insurance refusing to pay for ESWT

Dr. Z on 10/11/03 at 20:48 (133672)

So you did sign any consent forms giving the company, the doctor consent to do the ESWT procedure? I would first talk to your doctor's office and see where that leads you but the fact is if they didn't do the following then you have no responsbility
1. Tell you the fee in writing.
2. Explain in writing that if no insurance payment YOU must pay.

Again they may have all of approval information in writing already so lets first fine out what they have and then determine what can be done.
With ESWT the size of the company really doesn't mean anything as to how they operate. Excellence Shockwave Therapy Company has only seven people working for them and one is Dr. Z

Re: need advice from dr's insurance refusing to pay for ESWT

Ed Davis, DPM on 10/11/03 at 23:30 (133685)

David:

I will be the first person to express anger at the failure of many insurance companies to cover ESWT. Nevertheless, it was YOUR insurance company that did not pay. It is YOUR responsibility to find out if a service is covered. Doctors offices do all they can to give the insurers as much information as possible and argue in favor of treatments their patients need. Unfortunately, the doctors office has no ability to control what YOUR insurer actually does. You or your employer pay the insurer and have the ultimate say. If your employer provided you with the policy, you need to state your concerns to the HR dept. at work. If you bought the policy, you need to file a complaint with your state's insurance commissioner.

How much work did you put into comparing fees? Such services can and are done for less.

Now, if someone at the doctor's office related to you that the insurer assured payment, they did just that, related a message. That does not constitute a promise of payment -- a provider cannot promise what an insurance company will do and insurance companies often do what they please. 'Refusing to pay one dime' is the equivalent of taking something and not paying for it -- services have values just like commodities. If someone at the doctor's office promised you that your insurance company would pay, then you need to talk to the doctor because that person needs to be reprimanded or fired.

I realize your frustration but you need to assess blame where blame is due. The reasonable thing to do is to work with the doctor to reimburse him some fair affordable amount for his/her efforts based on mutual agreement and then take action against your insurer for failing to pay for a necessary and effective treatment.
Ed

Re: need advice from dr's insurance refusing to pay for ESWT

Dr. Z on 10/11/03 at 23:47 (133687)

Ed,
I agree that it is David's policy but in the state of New Jersey if the doctor performs a service without explaining the costs then he doesn't have to pay the fee. Anytime you are going to do an elective procedure such as ESWT you should explain the cost in writing and then have the patient sign that he understands the cost. All payment arrangements should be make in advance by the provider and or the equipment company. This is called good, fair business.
What the patient must understand also is that payment for a service is no guarantee that the service will be sucessful.
Fee explanations are just as important as quality of service.
But lets see what happen with David discussion with his treating eswt doctor and equipment provider

Re: need advice from dr's insurance refusing to pay for ESWT

Ed Davis, DPM on 10/12/03 at 00:37 (133692)

DR. Z:
We will have to wait to here from David to see if that was done. Most of the time only rough estimates can be provided since one does not know how an insurance company will administer the claim - unless insurers in NJ are required to provide that information -- they are not in WA. When we doe ESWT with Dornier, United Schockwave has a minimum payment that the patient is responsible for if the insurer does not pay. Sometimes such 'contracts' are called into question by insurers since they may imply that the patient is being given a better 'deal' than the insurance company.
Ed

Re: need advice from dr's insurance refusing to pay for ESWT

David B on 10/12/03 at 02:43 (133695)

Ok here is the deal, my doctor told me when he was telling me about ESWT that it is very expensive and if I give them a YES I will do it that they would do all the necessary work to find out if the insurance will cover this. I told him the ONLY way I would give them the OK of doing ESWT is if the insurance WOULD PAY. The doctor said YES I UNDERSTAND that. The doctor said he just don't want to spend all the time dealing with the insurance to see if they will pay and then me not do ESWT. It I made it very clear if insurance did not pay I am not having it done, and he understood that. They never had me sign a paper saying IF the insurance didn't pay that I had to. I believe its cut and dried if doctor and orthowave wants their money then they needs to take actions with the insurance company. After all THEY are the ones that told me my insurance would pay. Here is what makes me suspicious about the whole deal. I had to have ESWT done the 2nd time and they said we won't even bill your insurance company cause we know that will not pay for a 2nd procedure and since we have to give your anstheia if you pay us CASH we will only charge you 1/2 of what we did last time. Last time anstheia was $420 this time $210. I will be calling the doctor on monday. DR.Z what do I need to ask them?

Re: need advice from dr's insurance refusing to pay for ESWT

Dr. Z on 10/12/03 at 09:00 (133706)

Tell you story and see what they say

Re: need advice from dr's insurance refusing to pay for ESWT

Dr. Z on 10/12/03 at 09:13 (133707)

We know in most cases exactly what the insurance will pay for ESWT services before the procedure. Both from experience and in many cases we take the time to get to the correct person at the insurance to find out exactly what they pay. If there is a co-payment for the procedure doesn't the patient have the RIGHT to know the exact amount before a procedure is done. 20% of $2000 is alot different then 20% of $5000.
Those United Shockwave Contracts and Healthronic contract that do what they call a stop lost are completely illegal and are hurting the entire industry.
It is amazing if you know how to work your way with an insurance company what information that you are entitled too you can get. You have to understand ED that when I call the insurance company it isn't as Dr Z the podiatrist it is Dr. Z podiatric medical director of Excellence Shockwave therapy and I am dealing with the ancillory division of an insurance company not provider relationship.
It is really nice to be able to talk business with this insurance companies and at the same time know the procedure as a doctor.

Re: Should say tell your story and see what they say

Dr. Z on 10/12/03 at 09:15 (133708)

Should say tell your story and see what they say !!!

Re: To: David

Peter R on 10/12/03 at 09:37 (133712)

1- The most important part of this is 'Did you have any beneficial results from the treatment?'

2- Next- If the providers of the medical service feel justified in billing you and you refuse to pay the most effective weapon they have is to list the debt with the 3 major crdit companies. There it will sit until the next time you need crdit and you'll have to deal with it at that time. At that point you will have the choice of paying up to have the debt removed or taking it to court. If you are up against a time factor in getting the loan you need then court action will most likely be out of the question. I think that first the providers of the service had you by the foot and now they have you by the family jewels.

Re: To: David

Dr. Z on 10/12/03 at 10:35 (133722)

I agree the most important part is the result. I believe with David there was no releif
You can't just bill the patient a fee that was never explained BEFORE the services were provided.
It what David states is true I am sure and he didn't sign anything that stated he would be responsible for any monies that his insurance company didn't pay then in a court of law he would win his case.
There are alot of way to grap the family jewels of the providers who didn't inform him of the costs in writing. I am willing to bet that there is something in writing because to bill an insurancec company you must have what is called an assignment of benefits. In my office we have a standard clause stateing that if your coverage is terminated or not effective etc etc then you the patient must pay the bill.

Re: need advice from dr's insurance refusing to pay for ESWT

David B on 10/12/03 at 12:39 (133736)

Your right Dr Z I have had no relief from either shock wave treatment, now if the 1st time my foot was healed I would still be upset but I might consider paying for it on a payment plan, but IF I would have know the insurance would have never paid for it I would have just done A.R.T. which my insurance pays chiropractors. What I don't get they paid the anstheolgist $420, but will not pay the rest of the bills, does that make sense?? Oh on the bottom of the bill it said if you want to appeal this to contact so and so. I am calling my doctor monday morning and have a talk with him and tell him HE needs to appeal it if he wants his money!

Re: need advice from dr's insurance refusing to pay for ESWT

David B on 10/12/03 at 12:44 (133737)

The only paper I signed was the one that it was ok for the anstheologist to put me out.

Re: need advice from dr's insurance refusing to pay for ESWT

Dr. Z on 10/12/03 at 12:57 (133739)

You know my position on not informing patients the cost before the treatment. You didn't sign a surgical consent form Humm

Re: need advice from dr's insurance refusing to pay for ESWT

Ed Davis, DPM on 10/12/03 at 13:42 (133741)

David:
If I remember correctly, you had the Ossatron. Here is one of the big dilemnas I faced with Ossatron, from the financial point of view. There were 4 parties billing for the service. Too many in my opinion. There is the doctor/surgeon, the company that owns the machine -- Orthotripsy Services of Seattle in my area, Orthowave in your area, the anesthesiologist and the surgicenter. THAT is the Healthtronics 'model' and THAT is a big reason why there is resistance. It is too expensive a way to do things. The surgeon/doc can tell you what his fee is but he does not know what the surgicenter will bill, what the anesthesiologist will bill and what the machine owner (Orthowave) will bill. My proclivity is to offer the treating doctor and anesthesiologist a fair amount that you both can agree on for their services -- talking it over is always a good thing to do -- most people want to settle things fairly and nobody likes collection agencies.

You used the operating room for about 15 to 20 minutes and the surgicenter did not have to utilize sterile technique and prep the room as if a real surgery was done. I would call the director of the surgicenter and ask what an insurance company would pay them for 15 minutes of O.R. time, then ask for a discount, say 35% since they did not have to prep the room. Let them know that they can get a check for that amount now and be done with it or pursue you for payment. If they choose the latter, then send them a check for, say, $10 per month.

The next problem is the machine owner. If they had promised or implied payment, then I would have some stern words with them and they need to give you a substantial discount based on that.

Again, a big part of the problem is the treatment model which is just too darn expensive. When I use the Sonocur in my office, the patient gets only one bill for a very reasonable amount, from my office and no one else. When I use the Dornier, there are two bill, one from me, which I think again, is reasonable and one from United Shockwave which is higher but they basically guarantee patients that if the insurer refuses to pay, there is a reasonable out of pocket maximum expected from the patient. That amount, I beleive, just covers their costs. That policy is tricky because third parties argue that if a patient is provided with a price, then that price represents what the insurer should pay. In other words, insurers maintain that they should not get charged more than the patient for a service. That is a medicolegal grey area in my opinion. There needs to be a premium for writing letters and chasing insurers around for several months to try to get payment.
Ed

Re: need advice from dr's insurance refusing to pay for ESWT

Dr. Z on 10/12/03 at 15:34 (133756)

Ed,

We have a global fee which covers both doctors, equipment, tech etc. The patient is presented ONE bill. United Shockwave method is something that I feel is unethical and probaby illegal. Healthronics does the same thing.
Two Tier billing is illegal. !!!
Its Hey if the insurane company won't pay 6-7 thousand dollars then the patient is only responsible for $500 bucks. Come on. If that is true look at the mark up.
Remember it will always come back to bit you.

Re: need advice from dr's insurance refusing to pay for ESWT

Ed Davis, DPM on 10/12/03 at 15:49 (133758)

Dr. Z:
Keep in mind that you are among only a handful of docs to own their own high energy machine. As a consequence, there is usually a second party involved which is the machine owner.
Ed

Re: need advice from dr's insurance refusing to pay for ESWT

Dr. Z on 10/12/03 at 16:18 (133759)

Ed,
I am not sure what you mean? The machine owner such as myself enlists other doctors to use the machine. There is one major difference between United, Healtronics etc. A podiatrist owns the machine and at the same time does the procedure. This enable me to understand the patient market, the podiatric insurance market. Most of the companies out there are from the Kidney Stone companies. They have no idea about how the market works.
Doing a ESWT procedure in an ASC is so out of line with cost savings . I could go on and on and on.
Any company such as United Shockwave that charged a tech fee of 5-7 thosuand bucks is going to end of just like Heathronics.

Re: need advice from dr's insurance refusing to pay for ESWT

David B on 10/12/03 at 19:58 (133783)

Actually, the machine was the Dornier but the van the people were in said Orthowave. The people with the machine charge $3800, they did the procedure in the doctors office room and the doctor charge $1100 and the ansthelogist charged $420 which the insurance PAID! What do you call a fair amount for the doctor or the people that has the machine? Can they make me pay it all at once or sue me for the amount or can I just pay them $10 a month till I get it paid off with NO INTEREST? See I think I figured out what the deal is, I called healthlink when they 1st refused the payment 3 months ago. I said well my doctor had this procedure pre approved why are you not paying for this now! The insurance company said they never received anything from anyone. I called my doctor and asked him what the deal was and he said the people with the machine said they checked into it and the insurance would pay. I don't have a problem with paying my doctor his money but I do have a problem with paying the $3800!!

Re: need advice from dr's insurance refusing to pay for ESWT

Dr. Z on 10/12/03 at 20:03 (133786)

I have a question you may have answered this before. Did you have heel spur syndrome. This is where the person has pain stiffness and or limping after they first walk, after sitting for a length of time.

Re: need advice from dr's insurance refusing to pay for ESWT

David B on 10/13/03 at 09:26 (133822)

Tell you the truth doc Im not sure what I have there was no xrays ever done or MRI! I explained to my dr that it hurts like hell when I get out of bed in the morning or after I been on my feet for a long time. He said it was PF and started treating me for that. Im think its time for a new doctor. I want a doctor to take a MRI or an Xray and see what is wrong. I just got off the phone with the lady that does the billing and she said they got the same letter I did, They are going to appeal the case and she didn't mention anything about me paying. I told her if I would have known that the insurance wasn't going to pay I would have never done this!