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Can someone explain?

Posted by Pauline on 10/27/04 at 08:50 (162250)

I would like to know more about ESWT Groups or Providers, like United Shockwave and Dr. Z's large group Excellence in Shockwave, and any others that are out there. How many major providers are there and where are they located?

What is their prime purpose for doctors and for patients, and why do doctors that own their own ESWT equipment have the need to join one of these groups?

Are these groups in competition with each other and do they have anything to do with the price range for delivering ESWT among their members?

I don't think we've discussed this topic before, but now that these groups seem to be forming maybe patients seeking ESWT need to know their purpose.

Re: Can someone explain?

Connie H on 10/27/04 at 10:01 (162253)

Pauline,
I don't know all the answers...I'm just a pf sufferer, but from what I've learned as I've investigated ESWT, is that there are companies who purchase the machine, have trained technicians, and travel around to different Doctors offices (or hospitals) in order to provide the treatment. From my perspective, this enables more physicians to provide this treatment without the high cost of purchasing the machines, and it makes it more available to all of us. The United Shockwave Therapies have Dornier machines, and from what I can tell, they set the price for the treatment--and the doctor's fee is included in that price. From what I'm hearing as I'm calling podiatrists, that is $500 per treatment site (per foot). The Healthtronics group has the Ossa-tron machine, and they provide the machine, and their bill includes the technician, facility, and treatment, but not the anesthesiologist or the doctor. Their fee, in my region and it does differ from region to region), was quoted to me as $750 to $1500 out of pocket expense, depending on whether or not your insurance will pay anything, PLUS anesthesiologist PLUS your doctor's fee, whatever he can get. The company bills the insurance company $4000(!). So, I'm not sure what you're are asking, exactly. These groups seem to have found a way to keep these machines in use, without any one doctor purchasing it. It seems to me that if a doctor purchased a machine, it would be tempting to use it as much as possible, in order to pay for it. In this system, Doctors can schedule the treatments as needed...or not.
What do you think?

Connie

Re: Can someone explain?

Pauline on 10/27/04 at 13:15 (162267)

Connie,
If one large company is setting the fee for service for all of the doctors in their group why is this not considered illegal price fixing? It sounds like the ones you've called for Dornier are telling you the same price.

I can understand the ability to be able to supply more patients with treatment, but if you have only one machine and the number of doctors that are being serviced gets extremely large that machine is stretched pretty far so in reality how many doctors and patients can they serve effectively?

Being able to service many patients at lower rates is good for the patient, but there must also be a flip side to this arrangement. One has to ask whats in it for the doctors that sign up to become part of a group if they own their own machines? These doctors have no worry about being able to provide individual treatments because they have the machine already in their office.

United and Excellence are on the East Coast are there more companies as well and which providers are servicing the West Coast. Who are the ESWT providing groups. How many are there?

I guess what I'm asking about isn't about the treatment so much as it is the methods that have evolved to provide the treatment and the role played by these providers.

The person advertising for United on this site cut a while back cut his own wind and can no longer advertise ( post) here, but when he was posting he would only leave his email address for readers to contact him. He would never talk openly about United's program.

Most people probably don't concern themselves how these things play into the role of a patient getting ESWT, but I find it interesting to know the workings of providing ESWt from the inside out so to speak.

Re: Can someone explain?

vince on 10/27/04 at 18:44 (162287)

Connie, The information you posted about United Shockwave is not accurate. They do not set any fees with the doctor or the patient. They bill the patients insurance company for the technical fee and the doc bills for his/her professional fee. There is absolutley no fee charged to the doctor by United Shockwave for any aspect of the treatment. If the patients has insurance and the insurance does not cover the treatment then United Shockwave does not bill the patient. United Shockwave will provide their ESWT service to anybody with insurance(no medicare or medicaid)that does not cover ESWT WITHOUT A FEE. The only cost to the patient is the doctors professional fee. I don't know how many people must state this here before it is believed. If you need more proof call UNITED SHOCKWAVE in Chicago. How do I know this. Simple- They provided ESWT for me, my insurance did not cover the therapy and all I had to pay was the doctors fee which was very reasonable. By the way, that was 9 months ago and my PF pain is almost totaly gone. 18 minutes, a total of 5cc of Lidocaine and I walked out of the office, went back to work, and followed the docs instructions. And Pauline- please don't ask me any questions as I have read your posts for a long time and sometimes they are written so as to provoke and cast doubt. It must be terrible to be so mistrusting.

Re: Can someone explain?

Pauline on 10/27/04 at 19:00 (162289)

Actually Vince I'm glad you posted to clarify how United Shockwave provides treatment. I'm not trying to provoke doubt in anything or anyone, but I would like to know for my own interest how many companies
are providing these same services.

I see nothing wrong with seeking that information. I just am interested i knowing who the big players are when it come to providing ESWT treatments for the public.

Re: To Vince

Connie H on 10/28/04 at 10:35 (162321)

Vince,

I was just giving an opinion--I hope I stated that clearly. I apologize if I misled someone--Thanks for setting me straight. I have been quoted the same price by 3 different Podiatrists in the Dallas area, but yesterday, after I posted the message, I was quoted a price of $3000 to $4000 per foot for the same treatment, same machines, using United Shockwave equipment. Evidently, that podiatrist has a heftier charge than the others, or something. United Shockwave would give us no information over the phone, just told us to call the podiatrists. So, the information I shared here comes from my calls to those Doctors. I don't see price fixing here. I see free market at work. I'm thrilled to have a choice, since it'll be out of pocket. Thanks, too, for sharing your positive experience with ESWT. I appreciate that!
Connie

Re: Can someone explain?

Lynn F. on 10/28/04 at 11:35 (162331)

Echoing what Vince said. I paid $500 which was my dr's fee. U/S sent their ($6800) bill to my ins co. and THEY called me prior to my treatment, to assure me I would NOT be billed for any uncovered expenses. I'm just 3 1/2 weeks post treatment, still sore but noticing few bad days. Vince, I'm so glad to hear your success story! One can get pretty disillusioned reading some (not all) of the posts here.

Re: Can someone explain?

john on 10/29/04 at 06:30 (162386)

Lynn,

What was the name of your insurance company? Did you know ahead of time that they would not cover ESWT?

Re: Can someone explain?

Ed Davis, DPM on 10/29/04 at 23:05 (162461)

vince:
I use United and like their service. But are you not the guy who is making wild generalizations such as low energy not working because it did not work for you personally and that 'Naturopathy=quackery' on the Social Board. You, by making such outlandish statements cast a lot more doubt than Pauline is here. United, bills the patient directly for their co-payment and deductible and goes after the insurance company for the portion that the insurance company owes. They are holding the patient harmless for the insurance portion only as it is their intention to pursue the insurers based on the obligation of insurers to pay for modalities which are proven and work.
Ed

Re: Can someone explain?

Ed Davis, DPM on 10/29/04 at 23:16 (162462)

Pauline:

I was not aware of an add for United but United can post and have others post for them. They are a fine organization. Their website is http://www.unitedshockwave.com Also http://www.sonorex.com has a locator for machines placed throughout the US, more commonly with orthopedic groups.

There are a number of 'players' out there and I don't know all of them. United is in 22 states, to the best of my knowledge. Consider doing a search as I am sure that you will find a number of providers and companies. One way to find more information is to check around with providers and see which companies they are using -- it is a bit of leg work but if you are curious enough, the goal would be to check different regions of the country as you may note that most companies tend to have a regional base. Dr. Z is located in NJ and am not sure how far he takes his machine.
Ed

Re: Can someone explain?

Lynn F. on 10/29/04 at 23:31 (162465)

It was Aetna, and yes, I knew before I had it done. Thanks.

Re: Can someone explain?

john on 10/30/04 at 07:51 (162481)

Ed,

Your representation of United is not true. United does not charge co-pays or deductables when the insurance doesn't cover ESWT. Furthermore, discussions on this website mislead patients about the true costs of using. Sure if a patient has Aetna then the only cost is the podiatrist's fee but if the patient's insurance company covers the procedure then United charges $6,500 and the patient is responsible for all copays, deductables and non-covered fees. In many cases the patient's obligation exceeds $1,000.

If I were considering ESWT, I would change insurers to Aetna and get it done by a United podiatrist. The only cost would be the podiatrist's fee. I would talk to the podiatrist about his role in the procedure, get him to admit that he only does an ankle block and then ask how he can charge $500 for an ankle block and 20 minutes of office time. I would ask him how he can sleep at night. Maybe, the podiatrist would reduce his fee.

Re: Can someone explain?

Pauline on 10/30/04 at 10:08 (162492)

Dr. Ed,
If an insurance company has decided not to cover a procedure/treatment why are they still responsible to cover that cost for an insured? I don't understand that. If they don't cover it in the first place and tell the patient up front that treatment isn't covered I don't think they owe anything to the provider.

Am I miss understand the point that you are making?

Re: Can someone explain?

Ed Davis, DPM on 10/30/04 at 10:14 (162493)

John:

I cannot speak for United's policy in your state but for my patients, in my area, United DOES hold the patient responsible for their co-pays and deductibles. I think that it would be illegal not to do so. Co-pays and deductibles are NOT to be written off by any party except in cases of hardship and on an individual basis. The reason for this is simple: if one routines writes off a copay then the fee minus the copay becomes the 'true' fee being charged. United must present insurers with a consistent charge for services as their goal is to hold the insurer to THEIR obligation to pay for a service, that is, they cannot hold the insurer responsible for the patient's portion (deductible and copay).

You may want to double check with United in your area because I don't think that the legal issues I mentioned above should be very different from state to state.
Ed

Re: Can someone explain?

Pauline on 10/30/04 at 10:15 (162494)

Dr. Ed,
There was a poster, maybe the very first MARK that talked about a way for posters to get cheaper ESWT treatment. He wouldn't post the information directly, but left an email address for people to contact him.

After that a discussion arose about the 'way' the company which MaRK was talking about was doing business. He was speaking about United. Well to make a long story short or you can go back an look at the posts unless they were removed Mark got angry and said some nasty things to Scott R and Scott R banned MARK from posting anymore. So any advertisement that Mark was sharing via his email address was cut.

Now no one mentions Uniteds program.

Re: Can someone explain?

Ed Davis, DPM on 10/30/04 at 10:21 (162495)

Pauline:

This is not exactly a 'black and white' answer nor area of law. An insurer has a contract with the insured to provide coverage for condiditions with modalities that have been reasonably effective for such treatment. An insurer, in failing or refusing coverage, after they have entered into that contract, is violating their promise to the insured. United, is, apparently, trying to compell insurers that say 'no' to act consistent with their contractural obligation with their pateints and, via the appeal process, say 'yes.'

Pauline, Bruce Cohen is the attorney for United in Chicago. He can probably elucidate this better than I. It would be very interesting to bring him to this board, but keep in mind, we are doing so 'non-anonymously' so, as an attorney, expect caution to prevail in his responses.
Ed

Re: Can someone explain?

Ed Davis, DPM on 10/30/04 at 10:26 (162498)

Pauline:
I just don't know who Mark was. Nevertheless, when you say 'no one' mentions United, you may really mean that there is not one individual who acts as a regular promoter of United on this board. I certainly invoke the name of United all the time here as do a number of posters.
Ed

Re: Can someone explain?

Pauline on 10/30/04 at 11:03 (162503)

Dr. Ed,
You're correct you do invoke the name of United, but I don't think you promote it in the sense of providing patients with a list of United's doctors. I never contacted MARK but perhaps he was offering names of specific doctors near the callers home location.

Re: Can someone explain?

Dr. Z on 10/30/04 at 11:43 (162505)

Ed,

From what New Jersey attorney's tell us this is very clear and is in violation of State Board regulation and possible anti-trust law.

Re: Can someone explain?

john on 10/30/04 at 12:05 (162510)

Dr Ed,

My point is that the copays and deductibles for United are very high since they are charging $6,500. Consider a patient with a 20% copay. Their copy would be $1,300.

Re: Can someone explain?

Dr. Z on 10/30/04 at 12:16 (162513)

John,
So the insured patient is getting ripped off. He pays his premiums and then has to pay a high deductible and co-pay because his ESWT is covered.
The fee structure should be like they do in ESWL global !!~. One fee to be distributed to the doctor, equipment. If the case has to be done in as ASC then the fee for this is included in the structure. There is just no reason to place ESWT equipment into a hospital and or ASC location.

Re: Can someone explain?

john on 10/30/04 at 12:28 (162519)

Ed,

My point was that if you have insurance coverage, United will be the most expensive way to go since their base charge is significantly higher than that charged by other providers. Furthermore, if they are out-of-network then the patient is responsible for the entire amount minus the insurance payment.

Do you really think that United's charge of $6,500 is reasonable?

Re: Can someone explain?

john on 10/30/04 at 12:39 (162520)

Dr Z.

That is exactly my point. The insured patient is getting ripped off! The podiatrist tells the patient that ESWT is covered but fails to tell them that United charges the highest fees in the country. The patient receives the EOB and then reality hits - over $1,000 in payments are due United for the 'covered service'. The patient complains to the podiatrist, who in many cases is an owner in United, and the podiatrist says that he has no control over the price charged by United. In the end, the patient pays too much and is stuck.

I doubt that United podiatrists are even telling their patients that they are investors in the equipment that they are recommending. In many states, failure to disclose an investment by the podiatrist is a violation of the law and gives the patient the right to refuse payment. It is a state Stark Law.

Re: Can someone explain?

Pauline on 10/30/04 at 13:54 (162526)

I thought Stark only refered to Medicaid/Medicare patients? United will not treat them so I don't think they are in violation of Stark.

Re: Can someone explain?

Dr. Z on 10/30/04 at 14:10 (162528)

John,
Its true but sad. The insurance companies are starting to catch on with this operation. Take a look at the past history of United and price fixing. I watched in my area how insurance companies would pay for low energy treatments with the Sonocur . In my area the insurance Companies were ( not now) were paying doctors three times for three separate treatment. There was no global period so they could bill three or more times for the procedure
It took them over one year to straight this out when they were told this in the beginning.
I place some the blame on the insurance companies and the rest on greed .
ESWT is such an effective procedure that can be delivered at a fair price to an insurance company without all of this bull. Just look at the ESWL it is here for all to learn and practice by.!!!

Re: Can someone explain?

Dr. Z on 10/30/04 at 14:13 (162530)

Stark regulations also apply to state laws and state board of medical examiners regulations. In our state it is called the Cody Bill. The reason they avoid the medicare/medicaid patient is because the gov. has more power to destroy you then a state regualatory body, but the regulations do apply

Re: Just a "footnote"..

Lynn F. on 10/30/04 at 14:18 (162531)

My dr. did, in fact, tell me he was an investor in the equipment prior to my treatment. Perhaps this is why I was not all the 'shocked' when, for $500, he basically stood with hands in pocked while United tech administered the shockwaves.

Re: Just a "footnote"..

Lynn F. on 10/30/04 at 14:19 (162532)

My dr. did, in fact, tell me he was an investor in the equipment prior to my treatment. Perhaps this is why I was not all the 'shocked' when, for $500, he basically stood with hands in pockets, while the United tech administered the shockwaves.

Re: Just a "footnote"

Lynn F. on 10/30/04 at 14:23 (162536)

Sorry for the multiple posts (?)

Re: Can someone explain?

Ed Davis, DPM on 10/30/04 at 15:00 (162541)

John:

I agree that the charge is high. But you also have to consider the expenses United is incurring -- placing the machine on a mobile van, employing an ultrasound technician to be on the van and last, but not least, doing battle with 3rd parties.United has to employ a full time attorney to take on the third parties. Quite frankly, this is an area that drives US medical costs up considerably --- when you go to a medical office in the US, the back office staff is bigger than the front office staff (those involved in patient care). It is the reverse in Canada.
Another thing to consider is that United often does not 'win' the battles with third parties so they have to write off a lot of their fees. How much they are writing off, I do not know. The Ossatron treatment model is significantly more expensive because one must go to a surgicenter or hospital, utilizing an operating room and anestheiologist. Canada and Europe have come to the realization that the most cost effective way to go is low energy as it can be done comfortably, expeditiously and at low cost.
Ed

Re: Can someone explain?

Ed Davis, DPM on 10/30/04 at 15:09 (162545)

Pauline:
I am a provider for United. The website I provide, http://www.unitedshockwave.com provides a list of docs using United. What more do you expect me to do?
Ed

Re: Can someone explain?

Pauline on 10/30/04 at 15:24 (162550)

Dr. Ed,
I think you're doing just fine. I have no problem with you being a United provider. If they provide cheaper ESWT, people should know about it. I have no problem with you using a low energy machine either. You own it, you can use it.

What I have a problem with is when everyone thinks that treatment was sooooo great when Sonny was posting about it here, but when you even try to mention it you're cut down.

I guess as long as it stayed in Canada it was ok, just a terrific treatment, but not here with American doctors like yourself using it.

Doesn't that make you want to ask WHY too?

Re: Can someone explain?

Ed Davis, DPM on 10/30/04 at 15:39 (162553)

Pauline:

I am a provider for Sonorex too and you can find me at http://www.sonorex.com
I had sent patients on a 3 hour drive to Vancouver, BC before we even had ESWT in the US. My feeling is that BOTH high and low energy work and support everyone who is providing the service at a reasonable cost. I am against the 'infighting' between manufacturers and providers as I feel that that infighting is confusing readers here and that third parties can use disparaging remarks about competitors products and protocols as a way to deny treatment.

I do think that those who have invested in high energy have. potentially, money to lose if low energy is shown to be more cost effective and that can be a motivation to argue against low energy. We have had posts here from Dr. Jan Rompe, David Lowy of Sonorex in Vancouver and Sunny Jacob, each of who supports low energy, have had years of success with it.

I would ask and advise everyone in the industry that the real goal is to cure as many people as possible and that we should not fight over the tiny slice of the treatment pie that ESWT represents but to obtain a bigger piece of the pie. It is hard to envision the Ossatron model becoming more cost effective although I feel that it works. The beauty of Dornier is its ability to be used in multiple energy settings, high, low and in between so as more application come forward, that mmachine will potentially see more use than others. For now, focus is to get out the good word and get patients cured. It will take a certain 'critical mass' of patient cures until the third parties can no longer say 'no.'
Ed

Re: Can someone explain?

Dr. Z on 10/30/04 at 16:49 (162558)

How about because the Sonocur has no FDA approval for Plantar Fasciitis> Hey ever find out where the line came from why are you so obtuse

Re: Can someone explain?

john on 10/30/04 at 16:52 (162559)

Pauline,

State 'Stark Laws' refer to physician referral of all patients in the State.

Re: Can someone explain?

john on 10/30/04 at 17:02 (162562)

Dr Davis,

Are you also an investor in United?

Re: Can someone explain?

john on 10/30/04 at 17:14 (162564)

Dr Davis,

You really missed the point. Insurance companies are saying that there are no double blind, placebo controlled studies showing that low energy is effective. Evidence based medicine requires proper research in order to make medical conclusions.

United's treating thousands of patients will not convince insurance companies to cover ESWT because the patients being treated are not part of a controlled and are subject to treatment bias. It is a fact that the majority of patients with plantar fasciitis get better with time. Insurance companies need to determine whether the improvement is related to ESWT or the natural progression of plantar fasciitis.

Everyone seems to see conspiracy around every corner. Please just provide the studies that the insurance companies want and we can move forward. Over the time that I have been reading this board, several good quality studies could have been completed and published.

I want to repeat this point. 'If you want see ESWT universally covered, ask everyone in the industry to conduct the proper studies!'

Re: Can someone explain?

john on 10/30/04 at 17:23 (162565)

Dr Davis,

How do you reconcile the fact that United charges three times as much as Dr. Z?

I reconcile it by noting that most United investors have made a 100% return on their investment over the past two years. The extra money United is charging is going directly to its investors.

Of course United has a staff attorney, as well as a staff accountant. For a company United's size, with as many investors and legal filings, a part-time attorney would be more expensive than having an attorney on staff.

Re: Can someone explain?

Ed Davis, DPM on 10/31/04 at 00:23 (162591)

Dr. Z:
Paying three times is proper if the procedure (low energy) is billed properly, that is 0020T-58. The '-58' modifier means a staged procedure.
Each one of the 3 is about 1/3 of the cost of one high energy treatment.
Many procedures are staged and that is why the 58 modifier exists, to properly identify such procedures. Now if someone was billing the whole amount 3 times, that would be improper but am NOT familiar with anyone doing so. It is always possible to find a scoundrel but one should not generalize to criticize others who honestly provide the service and bill honestly.
Ed

Re: Can someone explain?

Dr. Z on 10/31/04 at 08:41 (162612)

It wasn't billed correctly routinely. You are the only one I know that bills correctly.
Horizon Blue Shield never paid for low energy it was in their written policy but still companies, doctors, billed using 0020T times three due to no global period. They will pain in alot of cases three full times.

Re: Can someone explain?

Ed Davis, DPM on 10/31/04 at 14:04 (162631)

Dr. Z;
Sorry to say that we have such varied experiences with colleagues. Needless to say, you and I are both straight shooters. The people I have dealt with in the low energy arena have billed honestly and dealt with patients in a straightforward fashion. I think that readers, by reading this site, can educate themselves to see what consititutes proper, ethical billing practices and what does not. As for third parties, they need to spend more time listening to providers such as you and I and get their heads 'out of the clouds' as the 'wall' they place between themselves and providers (and often their patients) serves to benefit no one.
Ed

Re: Can someone explain?

Ed Davis, DPM on 11/01/04 at 15:54 (162723)

John:
There are no double blind placebo controlled studies whowing that surgical treatment is effective for treatment of PF so by your standards, surgery should not be covered. There is little evidence (even less) supporting the hypthosis of Baxter and the Baxter procedure. Why don't you request that that procedure or any surgical procedure for PF be treated via the same standards as ESWT? There are no such studies on ART, Dr. Sandell's cross fiber massage...the list goes on and on. The fact is that far less evidence exist on modalities that are covered with far less evidnetial support. If you want to raise the bar on low energy, then BE CONSISTENT and raise the bar on all of the other areas that are rountinely covered by third parties.
Ed

Re: Can someone explain?

Ed Davis, DPM on 11/01/04 at 16:36 (162727)

john:
United charges a lot more than I do with my Sonorex. Yet there are many insured who cannot afford the fees United gives them a way to get treatment. This is traditionally known as 'cost shifting.' What does a man do on worker's compensation who has not worked in months? He probably cannot afford to go to Dr. Z nor be treated by my Sonocur but HE CAN AND WILL be treated by United.
Cost shifting, like it or not, had been a traditional means to disseminate care to all in need in the US for several decades.
Ed

Re: Can someone explain?

john on 11/01/04 at 20:11 (162742)

Dr Davis,

I agree. I find it amazing that insurance companies are insisting on a higher level of proof for ESWT than they required for the surgical treatment. I don't agree with the current position taken by insurance companies related to ESWT. I think that ESWT works and I am tired, like everyone else, of fighting insurance companies.

My point is rather than fight over the current ESWT articles and what they prove, let's conduct a new ESWT study that addresses the insurance companies concerns. It would probably be quicker and easier to conduct a new study then argue with medical directors about the current literature.

In terms of raising the bar, my position is that Sonorex needs to get FDA approval for low energy ESWT for plantar fasciitis. I don't know enough about the other treatments that us discussed to make any statements.