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hospital based ESWT or physician office?

Posted by Gina on 7/09/04 at 09:14 (154918)

My insurance will not pay for ESWT but will pay for the surgery. As I would prefer a less invasive option first, I'm considering paying out of pocket for the ESWT.

My podiatrist (who is chief of podiatry at the hospital, and runs a residency program..so I'm hoping I can trust her) usually does the procedure as an outpatient hospital-based procedure, but has offered to do mine in her office, to keep the costs down.

My question is this -- if this can be done in an office setting, why is it usually done hospital-based?

My current suspicion (having worked for a hospital for 10 years) is that this is just one more way that the hospital can gain ever shrinking patient revenues (and that's probably one of the reasons many insurances won't pay for it). But I am concerned that there are legitimate quality of care reasons. What are the potential risks to performing it in the hospital vs. the office?

FYI... my OB/GYN told me that his portion of reimbursement for my C-section was only $1200, yet the cost for the ESWT in the doctors office (private pay) would be $1100. I suspect this is why insurance won't cover this procedure -- reimbursement issues, not the question of appropriateness of treatment!

Re: hospital based ESWT or physician office?

Pauline on 7/09/04 at 09:54 (154923)

I am not a doctor just a former P.F. sufferer like yourself. There are two different high energy ESWT machines. One is called the Ossatron and one is called the Dornier Espos.

Many doctors have access to both machines. Treatment with the Ossatron machine is usually performed in an outpatient surgical center or a hospital because to receive this treatment the patient is usually put to sleep by general anesthesia. Because of this the OPC or hospital is used. There have been cases I believe that patients have undergone ESWT with this machine without being totally put out. Foot blocks and other medications may have been used instead, but it is believe more comfort is achieve by the patient being put to sleep.

The Dornier Espos on the other hand is usually performed in a physicians office or in a mobile unit that comes to the doctors office. The anesthesia for this treatment is not a general that will put you to sleep but a foot block and perhaps other local blockage for pain control during the treatment.

You might want to ask your doctor which machine she will be using.

I've not heard of any doctor providing Ossatron treatment in their office, but anything is possible. If this is the case I'd personally want an expert there to handle my anesthesia especially if I was going to be put completely out.

If I had to guess I think that she is going to be using the Dornier machine and not the Ossatron, but you'll have to ask to know for sure.

Both machines claim to be effective and both are high powered machines approved by the FDA to treat Plantar Fasciitis. The Dornier uses an on board ultrasound system to help identify your painful areas along with the doctors hand as he touches those trigger points on your foot.

To be honest we have heard both good and bad results and some middle of the road results posted here about both machines. If you have the time and desire you can do a search of this website to read what others have to say about their own experience with this treatment.

You might consider telling your doctor that you've learned there are two high power FDA approved machines and ask her which one she will be using on you. You can then ask her if she has found any difference in the expected results from either machine from treating her patients.

My medical disclaimer:
I am not a doctor and the above post is simply my personal response.

Re: hospital based ESWT or physician office?

Ed Davis, DPM on 7/09/04 at 15:23 (154978)

Your comment about reimbursement being difficult due to lack of hospital basing of the modality is inciteful. Dornier is generally office based with use of local anesthesia.

Re: hospital based ESWT or physician office?

Gina on 7/10/04 at 09:13 (155026)

Thank you both...

I have read some of the message boards as well as some other web sites. If I had to guess, I think I'm on the right track with trying the non-invasive approach first and holding out surgery as a final resort.

Is there any substantial different in success rates between these 2 different machines?

Does this cost of $1100 sound reasonable? The office said the doctor's charges are usually $1500, but we all know that they never get what they charge and the usual insurance reimbursement is much less. I asked the office if they would consider allowing me to pay what the insurances usually reimburse them and thats the price they came back with. I'm just wondering how much negotiating power I may have to get the price down lower, given its private pay.

Re: hospital based ESWT or physician office?

Pauline on 7/10/04 at 09:59 (155037)

As I said I'm not doctor, but it never hurts to try and negotiating for lower prices anywhere. Without the insurance coverage, my own personal opinion is that doctors might be willing to provide in office treatment or mobile treatment for less especially to those with the courage to ask.

When you think about it what is the worst that can happen---they say no. The best---you get a lower price. Who knows like a dealership prices may drop toward the end of the month. It never hurts to ask. You can even ask other doctors in your area what they are charging. Without insurance coverage if their machine is collecting dust there may be more negotiating room than you think.

I personally think you should ask your doctor about the success rate SHE has experienced with these machines.

If you look back at posts you can spend hours reading arguements and studies and data here all associated with an answer to your question, but when all is said and done all the data in the world will not predict your personal outcome.

You might want to do a search under the name of Elliott. Elliott was or maybe still is a P.F. sufferer. He examined a lot of the data that was published in medical journals on these machine and posted in plain terms on this site.

He had no monitary ties to any machine, so my personal take on his posts is that they were very forthright.

Lately it appears to me that with ESWT that you pay your money and take your chances. The same would be true about surgery, however, there are certainly more risks involved with this choice.

My medical disclaimer,
I am not a doctor and I do not have any monitary ties to any ESWT treating equiptment. My post is strictly a personal opinion and anyone considering ESWT should ask questions from their personal doctor prior to having it performed for any reason.

Re: hospital based ESWT or physician office?

MARK L on 7/10/04 at 10:16 (155039)


Currently, one of the major ESWT companies using the FDA approved DORNIER EPOS ULTRA will bill your insurance carrier and if the therapy is not covered there will be no charge to you for the technical component(patients with medicare are not currently being treated)). This leaves you able to negotiate only the professional fee with your doctor. This companies service is available at this time in about 30 states. e-mail me @ <(email removed)> if you want further info.

Re: hospital based ESWT or physician office?

Dr. Z on 7/10/04 at 11:03 (155047)

Be sure to ask if the fee includes aftecare, possible 2nd treatment and any other items that maybe be needed

Re: hospital based ESWT or physician office?

Pauline on 7/10/04 at 11:25 (155050)

This sounds like such a good deal for posters why not just post the name of the company and list all the states where it's available?

It also sounds like something Scott could post on the web site for readers looking for treatment in their own state. When the opportunity is over or comes to an end he can pull the information.

If Scott could post this informatiion many would see it and be able to take advantage of the assistance, other than that one has to be lucky enough to find your post to get the information.

Re: hospital based ESWT or physician office?

Dr. Z on 7/10/04 at 12:08 (155052)

There is alot more involved. Do your research and review the old posts with regard to this specific area.

Re: hospital based ESWT or physician office?

Pauline on 7/10/04 at 14:46 (155055)

Dr. Z,
I feel your response could lead a reader to think that there is something underhanded at work with regards to securing ESWT treatment this way.

I don't recall any other posts specific on this topic accept one other by Mark asking people to contact him. Each email address is different which makes this reader uncomfortable especially since the information seem to be quite secetive. Why is that?

What Mark is talking about sounds like a great opportunity for many people why can't it be made public on Scott's site?

Re: hospital based ESWT or physician office?

mikem on 7/10/04 at 15:13 (155057)

Gina, I had mine done yesterday in a surgical setting. There are two reasons why. The first was that a significant amount of local anesthesia was required to numb my foot. Doing it in a surgical setting allowed access to hospital resources should any reaction occur.

The second reason was that some people apparently need or prefer vercet to calm them down. That should only be taken in a hospital setting.

I had mine done with a dornier device, 3800 impacts, 13000 mjoules and am feeling pretty good today. It has taken 24+ hours for the anesthesia to wear off but so far, so good. Absolutely zero discomfort both with the procedure and recovery.

Good luck!


Re: hospital based ESWT or physician office?

MARK L on 7/10/04 at 16:34 (155060)

If you needed a significant amount of local than it wasn't injected properly. The PT and Sural nerve block, expertly administered should require a total of not much more than 5cc of 1% Lidoacaine. I have watched it done many time with less than 5 cc. A Podiatrist I know does it all the time with a total of 3cc of 1% plain Lidocaine and the patient feels nothing during the ESWT therapy. He just looks for the nerve and when it's found it's knocked out in a flash. If he's doing a bilateral he'll add 1 cc of .5% Marcaine to the second foot. However, I know that there are some out there who couldn't hit the nerve if it had an arrow pointing to it and a sign that said 'Inject here'

As far as naming the company with the very liberal payment policy- I won't use this site for commercial purposes.

Re: hospital based ESWT or physician office?

MARK L on 7/10/04 at 16:40 (155061)

Additional info-

The surgical center setting is preferred because many different doctors can be serviced at one site in a day instead of a couple of docs each in their seperate offices. It's a question of being able to do more therapies in a given day. Also, some docs like to do it on the day that they are in the ASC so that they can fit the ESWT in with their surgical patients.

Re: hospital based ESWT or physician office?

Pauline on 7/10/04 at 20:08 (155066)

What illwill is created by naming a company willing to give payment breaks to suffering patients? The mere fact that they are willing to do so would appears to mean that they are not only inviting patients to their facilities but more than happy to provide them with treatment at a fraction of the cost.

Using Scott's site to help suffering patients find the facilities and the company to secure patients needing treatment would seem to be complementary to everyone involved.

A major complaint voiced by P.F. patients about ESWT has always been it's cost. Now that an opportunity is available to provide lower costs for them, the informatiion can't be made publicly available. This brings me back to my first question. What possible illwill or harm is created by publicly posting such helpful information for our P.F. sufferers?

Re: hospital based ESWT or physician office?

Dr. Z on 7/10/04 at 20:09 (155067)

Take your time and do your research. Any poster can . There have been discussion about this and various posting. I believe Bill . Remember him. Discussed and explained this method of free treatments. Remember the old saying you never can anything for nothing. I am surprise that you of all people are already to go for it

Re: hospital based ESWT or physician office?

Pauline on 7/10/04 at 20:11 (155069)

If there is a CATCH than our readers need to know about it. Why keep secrets when it comes to their health?

Re: hospital based ESWT or physician office?

Dr. Z on 7/10/04 at 20:13 (155070)

No its unfortunately a question of insurance companies refusing to pay for a technical fee unless in as ASC.

Re: hospital based ESWT or physician office?

Pauline on 7/10/04 at 20:16 (155072)

If you know, why not just spill it out. Much better for our readers to understand than to to leave them guessing.

Re: hospital based ESWT or physician office?

Dr. Z on 7/10/04 at 20:17 (155074)


I just reviewed the training tape from this liberal company that you are talking about. It talks about using alot of more anesthetic then you are talking about. I do agree that very little is needed only PT with Sural block is needed. I have done thousands of these blocks for ESWT and other types of foot surgery and it appears very simple but if you aren't experienced will take practice.
I am able to teach all of our doctors this technique and they pick it up due to the special methods of training I have developed

Re: hospital based ESWT or physician office?

Dr. Z on 7/10/04 at 20:20 (155076)

I never said there was a CATCH. Do your research.

Re: hospital based ESWT or physician office?

Pauline on 7/10/04 at 20:28 (155077)

I think I've done mine. It's others I'm worried about. A dangling carrot left for our readers. Maybe some inquiring minds will want to know.

Re: hospital based ESWT or physician office?

Dr. Z on 7/10/04 at 20:32 (155078)

Review the posts that were about this very subject. It will make this very clear why.

Re: hospital based ESWT or physician office?

Dr. Z on 7/10/04 at 20:33 (155079)

I am sure that you can dig up the posts and copy and paste. I am getting involved with this discussion anymore.

Re: hospital based ESWT or physician office?

Milly.T on 7/10/04 at 23:44 (155085)

Pauline what cured your pf and do you use orthodics and what kind? also what kind of shoes. I dont want sugery or shots. Sorry if I am wrong post but want to know

Re: hospital based ESWT or physician office?

MARK L on 7/11/04 at 08:07 (155096)

(email removed)

Anyone who wants info about the ESWT company and their fee policy can e-mail the above address.

I will place no further posts on this topic. I will answer all e-mails

Re: hospital based ESWT or physician office?

Pauline on 7/11/04 at 11:03 (155103)

You can read my P.F. history by doing a search under my name. Plenty of stuff stored.

To be brief, my last case of P.F. lasted a little over 3 years as did the other two. They were all about the same, and pretty much treated the same with only conservative treatments. No Surgery, or ESWT.

Along the way I've had several pairs of orthotics made, some hard as ice scrapers and the last pair soft. I've never been able to wear any of them. They sit in a bag in my closet.

If you read Scott's book you will find a list of everything I tried and did, including night splints, casts both hard and soft, crutches etc. You name it I think I tried it everything accept surgery and ESWT as I stated before.

The turning point for me with this last case was a cream that was brought here by Dr. Chris Reynolds. It was called Jade Cream. He was running a trial with some of the folks on heelspurs. I was away and didn't make the trial, but after reading about it here I contacted Dr. Reynolds and purchased the cream.

I will tell you up front that some people that tried his cream from here reported they had no results others had a positive reaction. Since I wasn't in the study I just used it and my personal experience was that it helped me.

I think the other advantage that I had is the fact that I do not have to work so I can rest when ever necessary. When the pain was at its worst
I was off my feet not in an office or standing on concrete. Personally
I think rest makes a big difference. My children are grown and out of the house so I had no responsibilities in that area. My husband was and still is great. When I'm down he is always up. He'll be by my side until death and do what ever it takes to help me. Because of this I am very grateful and blessed. I realize others on heelspurs don't have the support of family and cannot go without work.

Other than that, it was in Gods hands. I did what I could following Scott's book, had P.F. 3 injections,tried orthotics,casts etc. just as I said.

One thing that I also took was a supplement that Scott mentions in his book, Bromelain. It's a natural anti-inflammatory you purchase at health food stores. My stomach had all the RX and over the counter anti-ifnlammatories it could handle so I check this one out with my doctor and started taking it too. I also added a B12 tablet to my diet.


I also started stretching program based soome on Julies Yoga stretches and some that I found on my own. I do them faithfully and I also have my husband involved in helping me do my stretches especially my legs. They are gentle stretches. I use a double rocker thing, I forget its proper name but you can find the single type on Scott's product type. I like the double for stretching and I became a 'foot player' meaning everytime I sit down even now use cream to gently massage my feet, stretch my small foot muscles and help circulation, besides it keeps my feet soft.

As far as shoes, I think I've tried them all. I cannot wear Birks the arch is tooo high for me. I finally settled on N.B running shoes and Clarks clogs and sandles. I wear what ever I find comfortable at the time.
These two brands work best for me. I also wear a pair of Espirts in the shower and I purchaed a pair of good water aerobic shoes that look like running shoes. I can't remember the name. I use them in the pool.

Inside my running shoes I use a simple blue shoe insert from Dr. Scholls.
Nothing special they are blue and have two red spots on them one at the heel and one in the toe. They have no real arch to speak about. When my P.F. was bad I also taped. I used cheap tape from Target purchased in the bandade isle or near the foot products. I also went to my friendly shoemaker and had him fashion two thin 1/8' thick cork wedges that taper from the heel toward the toe. They are the size of my heel. I placed them under the Dr. Scholls blue inserts and just leave them there.

That's about it other than time. Time for my body to heal without being repeatly injured.

Please remember these are things that I did. I cannot guarantee that any of it would work for you or anyone else. Hopefully some of it would help you. Try the cheap stuff first.

Forgot one thing. Contrast water baths hot and cold water. Massaging in the warm water and switching to cold immediately afterwards. I think this does help to break the pain chain. You can do it as often as you'd like and I also used lots of ice following any massaging or stretching I did.

Wishing you luck and a speedy recovery.

My medical desclaimer.
I am not a doctor. The above post is strictly an account of my personal experience with P.F. and doesn't promise a cure to anyone reading it. Anyone suffering with P.F. should be seen by a doctor and follow their treatment plan. Doing any of the above suggestions is done at the readers own risk. All supplements mentioned in my post should be check out by the readers own physician prior to taking any of them. All readers should be aware that ice applied directly to the skin can cause harm and they need to take the proper steps necessary to prevent injury.

Re: hospital based ESWT or physician office?

Ed Davis, DPM on 7/12/04 at 09:57 (155155)

I have already posted on this. It is United Shockwave of Chicago which operates out of about 22 states which is doing this.

Re: hospital based ESWT or physician office?

Ed Davis, DPM on 7/12/04 at 10:02 (155156)

No guessing -- I have discussed this: http://www.unitedschockwave.com

Re: hospital based ESWT or physician office?

Pauline on 7/12/04 at 17:46 (155223)

Thank you Ed. Glad others will be able to contact these folks if the need help. There wasn't any need for Dr. Z and Mark to make it seem like a secret.

I hope others take advantage of the offer and the information you generously provided.

Re: hospital based ESWT or physician office?

Dr. Z on 7/12/04 at 18:24 (155229)


It wasn't a secret at all. I just didn't want to start with the legal implications but since this post is giving the appearance that I was holding something back I will respond . It is against the law to charge an insurance company one fee and a patient who has no insurance another fee as a POLICY. This is called two tier billing. If a patient is aware of this and goes to someone doing this then they can also be held responsible.
This type of billing where you charge thousands of dollars to the insurance company and then charge alot less is one of the reason insurance premium go up and why there is a decrease with ESWT coverage.

Disclaimer: I am not an attorney or am I stating that any specific ESWT vender is doing this as a policy. Pauline should retract her statement 'I hope others take advantage of the offer and the information you generously provid' cause she could be accused of referring patients to any group that as a POLICY is two tirer billing. Better get legal advice before you start to refer patients

Re: hospital based ESWT or physician office?

Ed Davis, DPM on 7/12/04 at 18:54 (155238)

Pauline and Dr. Z:

This whole issue surrounding billing is in a grey zone of law. I think that it is the opinion of the folks at United, that third parties should be covering it and that it is their intention (I would imagine) to fight for payment, in the court system if need be. It seems problematic now but it is my hope, that in the long run, they will be the ones that 'break the ice' for everyone concerning this modality and everyone will benefit.

Keep in mind that these are some of the same people (at United) that were involved when ESWL was new and fought hard to get that covered a number of years ago. I beleive that they view this as a repeat of that battle.

As far a two tiers, that is not what is occurring. They have a fixed fee, are billing copayments and deductibles to the patient. The amount that is due from the insurance company is what they are holding the patient harmless for since they feel that the third parties should be held to their obligation to pay for effective treatments for their insured. They are trying to 'insulate' the patient from the battle -- the patient has enough to worry about, just trying to get well. I really have to admire their willingness to 'go to bat' for this -- I think we, as providers, all have battle fatigue in trying to get insurance companies to cover the modalities and drugs our patients need.

Re: hospital based ESWT or physician office?

Pauline on 7/12/04 at 19:07 (155240)

Dr. Z,
Hoping that something will happen is different than making it happen.
Relax. I'm not worried.

Re: hospital based ESWT or physician office?

Pauline on 7/12/04 at 19:22 (155243)

Dr. Z,
I thought this was quite common. Many patients are given discounts for 'cash' payment as apposed to sending it to insurance. It seems to happen in the dentist's office a lot.

Personally I don't view this any differently than the 'discounted' figure accepted by a physican for treatment for a patient who has used a physican within their insurance network. Sometimes the physician bills $350 for squeezing a pimple and when all the discounting is done the doctor get $75 for the service. The patient without insurance coverage simply pays the $75 and walk out without any paper work to the insurance co.

Re: hospital based ESWT or physician office?

Pauline on 7/12/04 at 19:42 (155245)

I would think billing for services not rendered and or providing one treatment and coding for another would be worse violations.

I don't think our readers know that most insurance claims for treatment that has not be rendered is hardly ever returned nor do they go after it when informed by the patient.

The reason I know this is because it happened to me. Unless you check your statements you do not know that your insurance company was charged for a treatment that never took place or when in the hospital an item that you never got.

When an in office surgery showed up on my bill for a toenail removal and all my toenails were still attached to my toes, I called my insurance company. The doctor was paid for this surgery that never happened. I requested he return the money and it never happened until I told him I would march outside his office with posters citing wrongful billing practices that he returned the check to my insurance co.

Most doctors know what insurance companies policies are and how aggressive they are at collecting wrongful payments.

Re: hospital based ESWT or physician office?

Ed Davis, DPM on 7/12/04 at 19:52 (155247)


As mentioned, this is a legal grey zone. I could never see anything wrong with giving discounts to cash paying patients. When a patient pays cash there is no insurance company to pursue for payment (a major practice expense unto itself) and third parties often don't pay claims for months -- there is a time value of money. Finally, we already have multiple fee schedules becuase we have signed numerous contracts accepting different levels of reimbursement for specific procedures.

Billing for services not rendered is certainly a much more serious violation but even billing for unnecessary surgery is problematic. In other words, if we have a non-surgical procedure that is more successful than the surgical procedure, then there should at very least, be an obligation on the part of the doc to tell the patient about it. Now, if an insurer influences the patient's choice of procedure by covering surgery but not the more effective non-surgical treatment, and the patient gets a poor result due to that choice should the insurance company not pay the patient for adversely influencing their choice of treatments?

Re: hospital based ESWT or physician office?

Informing 1 on 7/12/04 at 20:40 (155251)

Dr. Ed:

FYI, maybe all are not aware of the history of United. Here is a piece from their past.


Parkside is owned and operated by United, see the following from their website;

'United Urology Centers, LLC For the past eighteen years, United Urology Centers, LLC, an affiliate of United Shockwave Therapies, has been widely recognized as a market leader in the use of extracorporeal shockwave technology. United Urology Centers was established in 1986 after the FDA approved Extracorporeal Shock Wave Lithotripsy (ESWL) for the treatment of kidney stones. Our first center, Parkside Kidney Stone Center, located in Park Ridge, Illinois quickly developed into one of the leading ESWL facilities in the Chicago metropolitan area.'

Re: hospital based ESWT or physician office?

Dr. Z on 7/12/04 at 21:53 (155254)

Pauline, Ed,

I will spell it out for you. There are two parts for ESWT services. The professional and the technical. Lets say that the insurance company won't pay for the technical conponent but will pay for the professional conponent. Now if the machine ( tech) is given for nothing then the doctor gets his professional payment from the insurnance company. Without the machine you can't have any professional billing.
Let to top this off the doctor is an investor in this ESWT company so he now has a finanical motivation to use this company all the time and do free treatment so that he can get some finanical reward from that bill techanical payment of say $80000.
This is why federal and state anti-knick back laws were written to remove any finanical motivation for performing service. Getting a piece of that big technical $8000 is sure a big motivation

Is it ok to give discounts not when it is POLICY. I once joked to a lawyer patient that if I hit the lotto I would open up a free clinic he told I couldn't because it was in violation of anti- trust.

Lets not make this a long stupid threat if you don't believe me ask your personal lawyer to explain anti-knickback laws in your specific state.

Re: hospital based ESWT or physician office?

Dr. Z on 7/12/04 at 22:02 (155255)


Actually the ESWL battle was won within six weeks . Medicare covered ESWL very quickly unlike ESWT.
Two tier billing is exactly what this is. Saying that your policy is that you will charge the insurance a fee and not the patient is two tier

I have been around the ESWT business for over five years now and it is this BullSh-T along with other things that is why there are insurance problems.
Atttention: We are losing the insurance battle for ESWT coverage. Why? due to the type of billing that we are talking about.
ESWT isn't ESWL.

Re: hospital based ESWT or physician office?

Informing 2 on 7/12/04 at 22:06 (155256)

Has Parkside ever been convicted of price fixing with Medicare?

Re: hospital based ESWT or physician office?

Pauline on 7/13/04 at 08:33 (155281)

Interesting post. From reading this article it appears that no guilty plea was ever entered that only a settlement agreement was reached and agreed to by all the parties.

It would appear to me that unless the same two doctors are still involved and violating this consent agreement these charges would probably have no real bearing on the way they are providing ESWT to current patients.

I think they would have to be brought up on new charges as this addresses services for lithotripsy and not ESWT if price fixing is again found. It looks like this hasn't happened to date so I don't think we can assume anything from reading the link accept the findings that it addresses as stated.

The old innocent until found guilty and with their ESWT apparently that hasn't happend yet. To assume guilt based solely on this article would be jumping the gun I think. Just my opinion and I am not a doctor or a lawyer or associated with this company in any fashion nor hold or make profit from shareholdings from it.

The proposed consent agreement to settle these charges, announced today for public comments, would:

prohibit the respondents from agreeing or attempting to agree to fix or negotiate prices, discounts, or other terms of sale or contract for lithotripsy services;
require USS, SCA, and USL to terminate third-party payer contracts that include the challenged fees at contract-renewal time, or upon the written request of a third-party payor; and
require USS, SCA, USL, and Drs. Norris and Rubenstein to notify the FTC at least 45 days before forming or participating in an integrated joint venture to provide lithotripsy professional services.
The proposed settlement also includes various record keeping and reporting provisions designed to assist the FTC in monitoring the respondents' compliance with the order.

Re: hospital based ESWT or physician office?

Tess M on 7/13/04 at 11:29 (155301)

I,too, refused to have the invasive surgery for my pf and appealed the insurance company twice only to be denied both times for ESWT. I then appealed to the NYS Insurance Board which rendered a binding decision in this external appeal in my favor. The insurance companies, I am convinced, don't have many subscribers challenging their decisions; rather, people just submissively accept the corporation's decision. It took a lot of time and paperwork to get my benefits paid for, but it does sometime work. The lesson: document every phone call, name, date and interaction with the insurance company, and do your own research. Create a paper trail. When you have all your ducks lined up, then start your appeal process.

Re: hospital based ESWT or physician office?

Dr. Z on 7/13/04 at 11:38 (155303)

How long did the process take you.?

Re: hospital based ESWT or physician office?

Ed Davis, DPM on 7/13/04 at 11:58 (155308)

I have read the information; thank you. I don't see parallels at this point. Medicare patients, to the best of my knowledge, are not involved.
If anything, the net effect of their current actions is to increase availability and bring down the price of the modality. When insurers cover a modality they essentially dictate, for the most part, the fee for the service. It should be apparent to many readers, that the health care marketplace does not operate in a 'free' market as do most industries.

Re: hospital based ESWT or physician office?

Ed Davis, DPM on 7/13/04 at 12:26 (155311)

Dr. Z:

I am familiar with Stark laws. One always reaps some financial 'reward' when providing a service unless that service is free or unless the provider is on a salary and that salary is not based on the volume of work being done. Certainly, being an investor creates an incentive to use a company's 'product(s)' although there are 'safe harbors' which includes the number of investors (I beleive that the number muut be over 50). In many cases anyone can be an investor and investors are a necessity when it comes to having adequate capitalization to obtain new equipment.

I have heard too many interpretations of 'disounting' that I cannot say for certainty how it would be looked at legally. There are free clinics out there that as a policy provide treatment at no cost.

Re: hospital based ESWT or physician office?

Dr. Z on 7/13/04 at 13:13 (155317)

Is ESWT excempt from the stark laws? I am talking about anti-knick back STATE laws and laws that are written at the state board of medical examiners level. Sooner or later we are going to find out.

Re: hospital based ESWT or physician office?

Ed Davis, DPM on 7/13/04 at 14:08 (155322)

Dr. Z:
ESWT is not exempt from the Stark Laws but would have the same 'safe harbors' as any other area of health care.

Re: hospital based ESWT or physician office?

Ed Davis, DPM on 7/13/04 at 14:18 (155324)

Dr. Z:
EVERYONE has multiple tiers in billing. When we sign contracts with numerous insurance companies accepting different amounts for the same procedures from different companies we have created such tiers. I don't see, given that fact, how anyone can challenge fee differentials given that fact.

Re: hospital based ESWT or physician office?

Dr. Z on 7/13/04 at 15:18 (155337)

How can you not be exempt from the stark law and at the same time have a safe harbor. ESWT as far as I know has no specific safe harbor as for example an ASC would or ESWL. It really doesn't matter cause Stark law only pertains to any federal insured group such as medicare, tricare etc. I am talking about state anti-knick back regulations. This is where I feel there may be a violation for any podiatrist that invests with a group and then does free treatments or receives a professional fee from an insurance company with the ESWT company as a POLICY not charging the patient any monies unless the insurance pays. This is a direct inducment to refer to this an ESWT vendor or invest with that vendor.
I really didn't want to start with this conversation and I think that this is between the podiatrists, United Shockwave( you mentioned them) and the legal experts in this area.

Re: hospital based ESWT or physician office?

Dr. Z on 7/13/04 at 15:28 (155341)

We don't bill different fees to different insurance companies. We do receive different payments. I don't know what the regulations are in your state but in New Jersey, this would be a violation of State Board of Medical Examiners.
I would image that there are alot of podiatric lurkers in this board. I will advice you to seek legal advice before you partake in this type of billing practice.
You aren't going to agree to what I am saying so lets just stop this conversation and go on to different topics

Re: hospital based ESWT or physician office?

Ed Davis, DPM on 7/13/04 at 19:40 (155352)

Dr. Z:
It is true that we may bill the same amounts to different insurance companies but we have signed agreements stating the amount we actually are to accept from each company which vary greatly. So the fact that we write down a 'standard' fee for a procedure is truly meaningless when we have, before hand, agreed to accept something different with each company. If regulations are on the books which appear to prevent that, they are meaningless and based on an antiquated understanding of the system, simply because the fee we charge is meaningless -- we are charging one fee but have agreed, ahead of time to accept something different from each insurance company. The average practitioner's office thus has dozens of different fee schedules, predetermined by insurance company contracts. The use of a 'standard' fee is an exercise in futility as that fee has no real meaning other than that is what we would like to get. If someone was to buy your A/R, they would have to convert all the data from the amount 'billed' to the amount each insurer will pay broken down by insurer.

Now, if each insurer can 'negotiate' a unique and different fee schedule with a medical office why cannot an individual patient do the same? The non-legal answer to this is self evident because insurers really don't 'negotiate' with us, they 'tell' us what the fees will be, take it or leave it. By the same reasoning, what would prevent a person uninsured for ESWT come to you and make you an 'offer?' As an individual, they would have less clout than the insurer but could you not consider their offer if it was different than the 'standard' fee charged? You already have given some insurers, perhaps a lower fee as they have so 'negotiated' it with you, different from that 'standard' fee.

Re: hospital based ESWT or physician office?

Ed Davis, DPM on 7/13/04 at 19:49 (155353)

Dr. Z:
An example of a safe harbor was if 50 or more individuals invested in a medical device, then it was okay to 'self-refer.' I cannot speak for individual states. It is the 'intent' for United to get paid so it is not for free but it is their intent to hold insurers repsonsible for their contracts to their insured. I agree that we are getting out of our league here as we are discussing legal matters that we have insufficient knowledge of so lets give this a rest....

Re: hospital based ESWT or physician office?

Ed Davis, DPM on 7/13/04 at 19:52 (155355)

Dr. Z:
Sorry -- I answered without reading your last sentence. As below, we need to put the matter to rest as we are getting out of our 'league' as these are matters for attorneys, not docs...

Re: hospital based ESWT or physician office?

Bill, jr on 7/16/04 at 19:54 (155659)

Dear Dr. Ed,

United is not operating within an Anti kickback safe harbor. I believe that this is one of the reasons that they will not treat Medicare patients. Likewise, United is also likely in violation of the Stark laws since ESWT is not exempt from Stark ( ESWL is exempt).

As far as I remember, there is no safe harbor related to the number of investors in a private company. There is a safe harbor related to the amount of ownership of a publically held company and to investing in companies with millions of dollars in assets, but nothing related to investing with 50 other referers in a medical device.

If such a safe harbor existed then 50 doctors could band together and buy MRI machines and refer patients. Remember the goal of the anti kickback statute is to remove financial incentives for refering patients covered by programs paid for by the federal government.

The financial incentive to refer is not diminished by the number of investors unless the return on investment is diminished. United's goal is create a nationwide closed system whereby their investors exclusively use their system and refuse to use competitors systems. This is why United's investors are practicing podiatrists and their investors must sell back their investment if they stop practicing medicine.

Re: hospital based ESWT or physician office?

Gino on 7/18/04 at 01:43 (155736)

Hi there!

Just want to share my experience about ESWT. I had mine done on May, 28th. A few days after my procedure returned to my podiatrist to remove the bandage around my foot , he confirmed what the anesthetist had told me about the local anesthesia required to numb my right foot but he said I got 4 shots around my ankle (he showed me where). I was told not to eat anything on the day of the procedure from midnight. Around 8-9pm I was feeling my foot again. Just next day I could walk with no pain like Mike described. A few days later though I felt the same discomfort but subdued. It's been almost 2 months and just last week I started PT with ultra-sound followed by exercises in the pool. Dr. recommended 3x week for 3 weeks. In the meantime, I will have my orthodic ordered according to the shape of my foot.

It's been a drag for me because I am an avid tennis player. I play tennis as often as 4-5 times a week and some times play league and local torneys. Just for the records: I have flat feet and start feeling some unusual discomfort every morning when I got up on my feet but then as day went by the pain apparently disappeared. I was one night while playing tennis that I felt an excruciating pain that mobilized my right foot on the ground momentarily until this big pain gradually went away. Next day had a shot of cortizone so I could walk again. After that, started the usual treatment with frozen bottle of water rolling under my foot periodically for 10-15 mins. and Naproxen as mentioned above for a few weeks until I turned to ESWT.

I've been going strictly by what my Dr. said. No exercises, no tennis and rest as much as I can. But my question really is how much rest is necessary in order to see some positive results here? I am computer enginneer and spend most of my time seated. Occasionally have to walk up to a co-worker or rest room and go and get my car at the garage. I read Pauline saying that rest was a big factor in the healing process. If I am advised to stay at home if I could then telecommute is an option for me.

Thanks for reading this dull long message of mine! :-)


Re: hospital based ESWT or physician office?

Pauline on 7/18/04 at 14:47 (155762)

I hope posters are reading this post and pay attention. This is one to keep on file.

Most people have no idea what is going on behind the scenes with ESWT.

The insurance gravy train hasn't come in yet, so more creative ways are needed to insure that the machines aready purchased with high hopes of larger earned income don't become dust collectors.

United may be a good example of this. Is it the only one, I doubt it. It's probably just the largest right now, but others could be following their lead.

The next time you hear that lack of insurance coverage is keeping the cost of ESWT high think again, look a little deeper and ask yourself who is the largest group promoting ESWT treatments.

P.S. Take it easy on me I've got a really sore leg and ESWT can't help it:*

Re: hospital based ESWT or physician office?

Gino on 7/22/04 at 11:23 (156052)

Dr. Z

If you are asking me, it took about 35-40 mins. I was sedated and really didn't see a thing but my doctor told me how it went. He said that my leg was vibrating so much that they had to hold it down steady to carry on the treatment. Before the treatment started I could hear a loud noisy coming from the surgery room where the machine was. They say it came from the machine and that's why they ask you to wear these headphones.

Dr. Z, what is exactly the cause of a spur? Calcification? Any kind of food that I should avoid?