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11/23/2013    Alan Bass, DPM

NJ Podiatry Society Needs Your Help Against Horizon Blue Shield (David Zuckerman, DPM)

Re: NJ Podiatry Society Needs Your Help Against
Horizon Blue Shield

Recently, our long battle against an arbitrary
change by Horizon Blue Cross/Blue Shield of New
Jersey (“Horizon”) in its reimbursement policy
with regard to extracorporeal shock wave therapy
for the treatment of plantar fasciitis/fasciopathy
ended in a trial-level court granting Horizon
judgment.

The theory behind our case against Horizon was
quite simple. Under a medical policy with an
effective date of February 23, 2001, Horizon
deemed ESWT to be “investigational.” However, this
policy was reviewed and revised on October 26,
2001, and ESWT was deemed “medically necessary”
for the treatment of chronic plantar fasciopathy,
if administered using devices approved by the FDA
and provided specified conditions were met.

This policy was periodically reviewed, and
sometimes revised, on a number of occasions
between 2002 and 2004. The policy was revised in
June of 2004, to specify an additional condition
for the treatment; that the patient had not
responded to prior conservative treatment. This
revision specified that only a “high dose”
treatment protocol would be considered medically
necessary, and that “low dose” protocols were
deemed “investigational.”

This remained Horizon’s policy until December 18,
2010, when Horizon abruptly changed its policy,
instituting a revised policy which categorized
ESWT as “investigational:” Extracorporeal shock
wave therapy (ESWT), using either a high- or low-
dose protocol or radial ESWT, is considered
investigational, as a treatment of musculoskeletal
conditions, including but not limited to plantar
fasciitis; tendinopathies including tendinitis of
the shoulder, tendinitis of the elbow
(epicondylitis, tennis elbow), stress fractures,
delayed union and non-union of fractures, and
avascular necrosis of the femoral head.

The obvious question was, and is, what caused
Horizon to change a policy that had been in effect
for nearly a decade, and classify a generally
accepted, beneficial treatment which it had
previously reclassified from “investigational” to
“medically necessary” in 2001 as “investigational”
again in 2010?

NJPMS argued that the policy adopted in 2004
properly reflected the consensus in the applicable
medical literature, which had not, in fact,
changed significantly between 2001 and 2010, and
that Horizon had no good reason for the December,
2010 policy change. The relevant medical
literature did not change between 2001 and 2010;
if anything, it was more favorable with respect to
ESWT in 2010 than it was in 2001, when Horizon
first adopted its policy that ESWT was “medically
necessary.” In fact, in its papers in support of
its cross-motion for summary judgment, NJPMS
detailed Horizon’s own medical policy manual, both
with respect to Horizon’s own definitions of
“medically necessary” and “investigational,” and
demonstrated that Horizon failed to follow its own
policies in re-classifying ESWT from “medically
necessary” to “investigational.”

NJPMS argued that Horizon was bound to follow its
own policies and procedures both on general
grounds, as well as on the basis that, as the only
“health services corporation” in New Jersey to
N.J.S.A. 17:48E-1 – 68, Horizon should be held to
a higher standard than a commercial health
insurer.

The Judge who granted judgment to Horizon did not
want to “make law” or be the first to flesh out
Horizon’s role in our state. He found that we had
no legal basis to compel Horizon to change its
policies. Of course, we were not trying to compel
Horizon to change its policies, but simply require
it to justify the reason for the December, 2010
policy change, which altered nearly a decade of
prior practices, and to justify the policy change
under its own criteria for determining whether a
particular treatment is “medically necessary” or
“investigational.”

Horizon did not do this in the lawsuit, and the
trial Judge did not require Horizon to do so.
NJPMS and the Board of Trustees has decided to
appeal this decision and we will be filing our
appeal this week.

Lastly, I want to clear up a misunderstanding some
seem to have. This misunderstanding seems to be
rooted in what others have written and published—
others who were not involved in our case and who
never seemed to understand what we were attempting
to accomplish. Our case was never about, or in
support of, a particular technology or modality of
treatment. It was about Horizon’s outrageous
actions contrary to all reason; actions that could
ultimately serve to narrow the scope of our
profession. In the government’s and the carrier’s
War on podiatry, we were striking a blow for our
profession and our patients.

Alan Bass, DPM, President, New Jersey Podiatric
Medical Society, abassdpm@optonline.net

Other messages in this thread:


11/25/2013    Jeffrey Conforti, DPM

NJ Podiatry Society Needs Your Help Against Horizon Blue Shield (David Zuckerman, DPM)

The NJPMS has filed a lawsuit against Horizon Blue
cross of NJ because that insurance company has
decided to not cover EWST (by any type of
provider).

We lost by summary judgement, and it cost us a lot
of money. Now, NPMS wants to spend even more of
our money by further pursuing this case.

I predicted the adverse EWST judgment and waste of
money from the beginning. I brought this up
several times at the Northern NJ Division
meetings. This was all about a procedure that Blue
Cross just did not want to pay for, just like
trimming calluses that are painful for non at-risk
patients. It was not a discrimination issue
against podiatry. It was a plan policy decision.

It was a huge waste of our hard-earned resources.

We (the NJPMS) is now thinking about wanting PAs
to work for us. This would be a disaster! The way
I see this working out is the PA learns from a
podiatrist how to (properly) do nail care, callus
care, matrixectomies, warts, ulcer care, proper
casting for orthotics, etc.

After the PA learns from us, they will leave the
podiatrist's office and bring those skills to a
large primary care group (which has a need for
someone with those skills who can do the work we
do and all the other work that the law allows them
to do for a primary care Doctor) and would pay
them more (because MDs get paid more for office
visits than we do) and we lose ALL those
referrals. Be careful for what you wish for, for
you may get it.

We should instead be spending our money on:
A) Work to allow properly trained nail technicians
work for us. They would be no use to any other
type of doctor's office. They would free the
podiatrist to do other procedures if he or she so
desires.

B) We should also work on allowing foot & ankle x-
ray techs to work in our office with a reasonable
amount of training, say, 40 hours.

C) Work on expanding our practice to allow
something like us being able to treat hand warts.
How frustrating is it when your patient comes in
with 15 foot warts and one wart on his hand and we
have to send them elsewhere. Now is the time to do
this since everyone acknowledges that here is a
shortage of all doctors.

We need to be proactive, not reactive.

Please feel free to respond. I would like to get
the community's feelings about this.

Jeffrey Conforti, DPM, Paramus, NJ,
jconfortiusa@yahoo.com

11/16/2013    William Sachs, DPM

NJ Podiatry Society Needs Your Help Against Horizon Blue Shield (David Zuckerman, DPM)

We all know that ESWT effective modality treat
plantar fasciitis and Achilles tendonitis. That
was never the issue.

Clearly, Horizon's (and every other insurance
company's) issue is their bottom line. How many
patients have we all had that have come in years
later praising the result of ESWT? The problem,
which we all know, is that more people are
inclined to have a procedure which is noninvasive,
with little or no side effects and allows them to
be back at work quickly.

I have been so frustrated with this issue that I
sent a letter to Governor Christie suggesting that
ESWT would keep people off the disability rolls
rather than have them out of work for 6-8 weeks
following surgery. He passed me on to the
insurance commissioner who responded as follows:

==========

Thank you for your email to Governor Chris
Christie regarding the availability of health
insurance coverage for certain types of shockwave
and plasma therapy. The Governor’s Office has
asked the Department of Banking and Insurance to
respond to your correspondence.

As you know, health insurance is not currently a
mandated type of insurance coverage in New Jersey.
This creates several different markets for health
insurance. The Large Group market, which includes
most employer-sponsored or self-funded plans, the
Small Employer market for employers with 2-50
employees and the Individual market for those
families and individuals that do not have access
to an employer plan. Additionally, many New
Jerseyan’s are also covered by Medicare and
Medicaid plans.

Additionally, each of these markets can have
multiple plans and each plan can have different
benefits and coverage levels. Therefore, exactly
what types of specialized treatments or procedures
are available under any particular policy will
depend on the terms and provisions of the specific
policy contract covering a particular patient.

As a regulatory agency the Department of Banking
and Insurance does not have the authority to
create laws or mandate that specific treatments or
procedures be covered by all health insurance
plans.

However, any patient who has received a denial
from the their company for these services, may
file an assistance request with the Department by
completing the secure on-line complaint form
available in the Consumer section of the
Department’s web site at: www.dobi.nj.gov. As a
physician or therapist is not considered a party
to the plan contract the assistance request must
originate with the insured.


Legislative Correspondence
Legislation and Regulation
NJ Dept of Banking and Insurance

============

William Sachs, DPM, Shrewsbury Township, NJ
wmasachs@gmail.com


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