From NorthJersey.com:
The New Jersey podiatrists’ association has sued the state’s largest insurer to block a new policy that says patients must go to a certified radiologist for ankle X-rays and diagnostic ultrasounds — and can’t get them in their podiatrist’s office — if they want to be reimbursed.
The policy was to have been implemented on Nov. 30, but has been delayed, according to Horizon Blue Cross Blue Shield of New Jersey.
The insurer, which covers more than 40 percent of New Jersey’s insured population, says the policy is necessary to make sure that X-rays are safely delivered and competently interpreted and that unnecessary imaging services are reduced.
The policy would apply to more than 900 podiatrists in Horizon’s network, 60 percent of whom have imaging equipment in their offices. Podiatrists are physicians who specialize in care of the feet and ankles.
“We would rather send our members to the best people in the field to read the scans with the best equipment that’s calibrated properly,” said Daniel Emmer, a Horizon spokesman. Patients will get the services they need, but this will cut down on unnecessary care that drives up insurance costs, he said.
But the New Jersey Podiatric Medical Society says the insurer will be denying reimbursement for services that are integral to the practice of podiatry and part of the scope of practice defined by the state Board of Medical Examiners.
Plus, they say, the new rules will inconvenience their patients and add to patient expense.
It “costs the patient time, inconvenience, more pain and triple the amount of money,” said Jeffrey Conforti, a Ridgewood podiatrist and past president of the society’s northern branch. “When they come to see me they pay the office a co-pay, then another co-pay to the X-ray facility and then to my office again when they come back.”
Horizon’s new policy “also applies to diagnostic ultrasound for soft tissue problems such as tendon tears, soft tissue masses and cysts,” he said — “problems [that] are very common in the foot and ankle.”
The policy does not apply to X-rays of feet and toes, which can still be done in a podiatrist’s office if the equipment meets the criteria established by Horizon.
Horizon announced the new policy in a Nov. 30 letter that described an expanded role for CareCore National, a company that manages specialized benefits like imaging services under contract with the insurer.
The letter said that physicians who expected reimbursement for certain imaging services would have to meet criteria set by CareCore and be credentialed by them. Among the services targeted were ultrasound, echocardiograms and nuclear medicine procedures.
Among the practitioners to be credentialed were primary care physicians, cardiologists, chiropractors, endocrinologists, various surgeons, obstetricians and gynecologists, orthopedists and pediatricians.
Physicians who refer patients to their own facilities for imaging services tend to recommend more of them and have less up-to-date equipment and experience than certified and accredited radiologists, said Emmer.
Robert M. Conroy, the podiatric society’s attorney, said he also represents two Cumberland County cardiologists who are challenging CareCore’s expanded role for Horizon.
Mercer County Superior Court Judge Maria Sypek set a hearing for Jan. 21.
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Now I don't know about anyone else, but how much does this bother you as a practitioner that a private insurer is demanding that our services must be CERTIFIED by a "selected" and contracted agency that I'm sure is paid based on how many radiographic examinations do not meet "medical necessity" and "criteria".
I hope that the NJPMS beats this down, and quickly.
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