Section: CME Category: Practice Management

Health Policy Update 2019

Franklin Kase, DPM

Frank Kase, DPM discusses the issues surrounding insurance plans as well as the relationships developing with medical organizations for podiatric medicine and how to apply that knowledge to run your private practice.

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  1. Recognize issues surrounding insurance plans and how to become more successful with that knowledge
  2. Report the relationships developing with medical organizations in achieving goals for podiatric medicine
  3. Relate the knowledge obtained to surviving in private practice
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    Release Date: 03/16/2018 Expiration Date: 12/31/2020

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  • TAPE STARTS – [00:00]

    Speaker: Let me invite our first speaker Frank Kase, DPM from California College of Podiatric Medicine in 1976, Board certified in foot and ankle surgery, fellow of the American College of Foot and Ankle Surgeons. He is one of the youngest recipients of Lifetime Achievement Award from the California Podiatric Medical Association in 2015. So with that being said, please welcome Frank Kase talking on Health Policy Update 2019.

    Frank Kase: Okay, let me see if I can figure this out. Good morning. Excuse me that I have a little bit of nasal congestion. Anyway, we have a lot to cover in a very short period of time. So I am going to kind of zip through this. You know, I speak fast anyway those of you see me speak before. So I am going to -- if I can figure this out, we will get going. Alright, we are going to talk about updates in health policy and there have been a number of significant updates in terms of what's going on since our last treasure hunt last year. But before that I want to just credit Rob Lee, Jen, Tamra, Mark for really having the foresight to put together such a great program and putting together a two-day program and putting together CME credit program and actually making this one of the best programs Southern California has ever had. So my kudos to them. Alright, let's see, so we did it. Okay, learning objectives, these are basically what we are going to attempt to do. You can read this. I think all these things are available is my understanding. But anyway, I am director of Taylor Medical, which is a group purchasing organization and I know I have to disclose that but I did it anyway. Okay, so in 2010 when Obama was president, we introduced the ACA, Affordable Care Act, as it's well-known and there are certain provisions that affect us and that's what we are going to discuss.


    Now, one of the things you obviously know if you read the newspaper, which I am sure most of you do, will read the news online or whatever we get the news from, you see that there's this attempt to repeal the entire Obama Care Act, Affordable Care Act and the guy in Texas, a judge in Texas basically issued a statement saying that the individual mandate is unconstitutional. Therefore, the entire act should be thrown out. But that's not happened yet and in fact in California we have sought to expand it. So California kind of is little bit unique. And we will talk a little bit about that. Anyway, one of the biggest issues, one of the things that affect us is what's called the antidiscrimination policy in the Affordable Care Act and that basically prevents a plan from discriminating against you for your license. It basically says that they can discriminate against you for fees if your quality of care isn't commensurate with that they feel you know other specialties are performing. The problem is that this has not been extremely enforceable. So we have all these acts on paper but unfortunately no body is actually going to enforce it. So varying reimbursement should be based on quality measures, not on licensure. We fought very strong for that. And if you remember way back in the day we had this thing through ERISA that said basically there was a limitation of podiatry benefits. If you remember those words, podiatry benefits like came out of Ohio and came out of Illinois and came out of number of places where the corporations were located here in -- they were here in California but their headquarters were either in those other states and they were allowed to put limitations of podiatry benefits. You know that I -- well you may not know but I wrote a resolution back in 2003 to the House of Delegates at APMA saying that there should no longer be anything called podiatry benefit.


    There should never be anything ever called podiatry benefits. It's foot and ankle care by anybody who provides it and that's how it should be construed. Well, anyway the Affordable Care Act eliminated that business about a limitation of podiatry care, supposedly. So there was a class action lawsuit filed by the Oregon naturopaths because they were being discriminated against as well and this sought remedy of enforcement against anti-discrimination and my understanding is still ongoing. So we don't know what is going to be the long-term status. The other thing I talked about last year is that one of the other provisions is that if you aren't a contracted provider, you can still have the patient signed something saying that you represent them in addition to assignment of benefits that you represent them and that all communication from the insurance company to the patient goes through you. Meaning that even though you aren't contracted, you still can get paid because the patient says you are basically representing them and there is a form on the APMA website, if you go on that you can find that as well. That's very important too. Accountable care organizations. One of the things that came out of the Affordable Care Act was this thing called accountable care organizations. I am not going to belabor that because that's a long talk in of itself. But right now what I want to tell you is that there are 900 plus private and public ACOs, Affordable Care Organizations, serving 32 million beneficiaries. That's both Medicare as well as the private sector and you can see that there was a significant amount of savings to the ACOs that survived. Many ACOs did not survive. That was started. Now, one of the advantages for and I recommend you belong to as many ACOs as you possibly can because as a specialist, you can belong to multiple ACOs whereas a primary care physician cannot.


    Primary care physician can only belong to one ACO. So you as a specialist can. That's vascular surgeons, orthopedic surgeons and us. Okay. So I recommend that we belong to those things. We get involved in the governance committees, we get involved in the financial committees, we get involved in all the committees we possibly can because it gives us greater visibility and understanding of who we are. Okay. Not allied health, we are part of the entire medical field. We are part of house of medicine. The only one you cannot belong to is you can't be a founding member of the ACO. That's in the law. Okay. This is really important. So one of the benefits of ACO system is that it basically saves the system a lot of dollars and as we go on in future of health care, we are going to see that becomes more and more important. So if you are a high cost provider, you are going to lose referrals, and you are going to lose out tremendously. You got to learn to be, if you haven't already become a very cost effective provider, not over utilizing resources. Now, one of the things that has been found is that ACCs, Ambulatory Care Centers, are a cost effective area to do surgery. However, you got to be cognizant of using very expensive implants, very expensive biologics and all that and there is going to be definitely some indications by insurance companies where they are not going to approve all of the devices and things that we are using presently. They are going to basically limit you and if you basically want to use more expensive device, it's going to be on you and/or the patient. So big brother is watching. There is no doubt about it. We are moving into a value-based health care system and big brother is watching. So be cognizant of that. Okay. Well, I am not going to be belabor this but you know all about the SGR, sustained growth rate. That's how MACRA came to exist.


    So what we deemed SGR accounted for total health expenditures and we were always at risk for losing benefit. Remember when we were basically waiting for Medicare to say that we aren't going to get a 20% hit and we already have taken some hits already. Well, now we went to MACRA and MACRA promotes value-based care. I am not going to talk a lot about MACRA because that's going to be discussed by Gabe and by Jeff. So I am not going into too much but I just want to tell you that what it does is it focuses on quality of care being delivered, value of care. That's what we are going to be looked at. Value of care and the two tracks that you use are MIPS, which most of you've known and participated in APM. Well, Medicare really wants us to all be on APM, although it's really difficult for us because if you look APMs are advanced alternative payment models and they basically include ACOs, advanced ACO, next generation ACOs, homecare models, medical home model, renal and oncology model. Most of it does not affect us yet but it's going to be changing especially as it comes to diabetic care because that's being recognized as a very big cost expenditure to the health care system. So merit-based incentive payment system, which is MIPS basically is where we are going to look at. You know how Medicare is doing. They are looking at quality, they are looking at improvement activities, clinical improvement activities, advancing care information and now cost. Cost wasn't a consideration until this year. Now, cost is going to become 10% of the MIPS total score, okay. So let's talk about -- without belaboring the MIPS issue, let's talk about the insurance exchanges. Well, you know that the insurance exchange is another condition that came out of the ACA. The exchange has basically allowed people -- the whole idea was to make sure that we had affordable care for everybody.


    That's what we really were doing and then with Obama Care Program, it was basically covering essential benefits. And the benefits I told you that we really wanted to make sure recovered are wellness, ambulatory services and things like that, which do benefit us. So in California the exchange is called Covered California. We have increasing amount of people joining that. Obviously, there is a whole thing now with the courts, with this Texas judgment that just came out whether it's going to continue and then there were four tiers of benefit. You can read that, Bronze, Silver, Gold and Platinum. Most people have silver where they pay 70% of the health benefit. The problem is that deductibles are so high. So before, we had multiple PPOs that were part of the healthcare exchange. Now, we only have two. We have Blue Shield and Health Net. And that's it. And one of the problems with Health Net is that if you remember those of you who were Blue Shield providers, you received the contract number of years ago that basically said that you were willing to except 70%, 80% or 90% of Blue Shield's payment, meaning that you can't balance build the patient. Well, that meant that if Blue Shield and I will show in another slide that Blue Shield pays approximately 90 something percent of Medicare or did pay something 90% of Medicare and you are accepting 70%, 80%, 90% of that, you can't balance bills. So you are getting paid either 56%, 63%, 72%, et cetera. So that's really an important consideration whether or not to go on the exchange and accept the exchange. You don't have to accept the exchange even though you are a Blue Shield provider, et cetera. One of the things that happen is that PPH, which is Providence Partnership for Health or Providence Healthcare System negotiated a fee schedule commensurate with the PPO schedule that we have with Blue Shield. So that's the only PPO for the exchange that I am personally on because I am part of the Providence Partnership for Health.


    And one of my hospital is providence. Okay. The essential benefits, we talked about that in ambulatory patients services, prevention and wellness. There are a lot of other benefits that don't affect us as much. Okay, now I am going to talk to you about some specific issues that do affect you. Okay, Anthem Blue Cross and we discussed this briefly last year but now it has become a big problem. Anthem Blue Cross set up in November of 2015 a policy that came out of their technology policy and policy people saying that they are no longer going to pay for casting for an orthotic. What they are saying is that it's included in the fabrication of the orthotic, which is totally ridiculous. But anyway nonetheless that's the policy. And then what they did was they started recouping money from people including me prior to that implementation of the policy, which was November of 2015. Okay. So recently they have basically said that if they paid you for casting either before or since that implementation of policy in November of 2015, they are now requesting money back. And we have got a list of about 50 doctors so far in the state that have been requested monies back from Anthem Blue Cross. Now, we are fighting that. We have actually -- I have discussed this with Keith Greer [phonetic] at length and we are considering filing a class action lawsuit against them or in junction at least to stop them from trying to get payment back because remember, they can take money back from future claims under Anthem Blue Cross. The other thing you need to know and maybe you do already but Anthem Blue Cross pays the lowest fee in the State of California for orthotics. They pay $138 in change per orthotic. That is the lowest ladies and gentleman in the state of California that I know of.


    And I pretty much know what's going on here. Anyway, bottom line is that the lowest fee besides that is $202 from AETNA and then Blue Shield pays about $215 and then United Healthcare pays about $250 when they pay and Cigna pays about $220 when they pay. So the other issue you need to know is that orthotist and prosthetist are getting paid between $207 to $225 per orthotic, which includes casting. That includes casting. They don't build for casting separately. That's kind of the way they are trained. Because AFOs you know build casting separately. And that's the way they are trained. Anyway, the bottom line is that here orthotist and prosthetist are getting paid 50% higher than we are at least and we are not getting paid now for casting and we are getting pain $276 for orthotics. They are getting paid about $414 to $450 for a pair of orthotics, which is ridiculous. That's the clear case, in my mind and I am not a lawyer, of discrimination. So we are not letting that sit is the bottom line. Okay. The other issue, which many of you probably are aware of is that we had -- anyway I just want to tell you that's an ongoing fight and we need to know if anybody else is getting letters, demand letter, from Anthem Blue Cross regarding payment for orthotics that they are going to recoup money back or they are you know saying that they overpaid you or whatever, you need to send that to either the CPMA office or directly to Keith Greer. Okay. That' really important and anybody else you know that’s in that similar situation needs to get that information. Okay. The other issue and this was a huge issue last year is if you remember that Anthem Blue Cross came out with a policy saying that they are no longer going to pay for 25 modified, they aren't going to pay in evaluation management service at the same time they paid for a procedure done at the same time with 25 modifier.


    And then it was reduced down to 50% and then it was reduced down to 25%. I basically put together a coalition with -- Tony Pujol [phonetic] actually turned me onto the right guy to talk to and I have been a consultant to Anthem Blue Cross for about 20 years. Anyway, so we got to the right person and I was the only person in the state that they would talk to -- the Anthem would talk to. CMA couldn't get a meeting with them. COA couldn't get a meeting with them. The dermatologist couldn't get a meeting with them, but we did. The bottom line is we did and I put together a coalition of the California Medical Association, California Orthopedic Association, California Dermatology Association. I had Harry Goldsmith, may he rest in peace, on my committee as well. And the bottom line is that we saved millions of dollars for all docs because they eventually came out with a statement saying that as of February 2018 they completely rescinded the policy where there were no longer going to not pay for a 25 modifier for E&M code when they did -- you had a procedure and the procedure by the way wasn't just like doing a procedure in the office. It was doing like even a cortisone shot or strapping. That was considered a procedure. And they weren't going to pay you for the E&M whether it'd be a new patient or an established patient. If you did any procedure at all and by the way that not only affected podiatry, that affected all of medicine. So that was the first time that we were actually fighting not only for us at a proprietary way, we were fighting for all of medicine and we won. We beat them. I got a call from the California Medical Association president in February of 2018 saying that Frank, you did it. We beat them. And I called Devine Glazer and he was basking in the sun in Cecily or in Italy or somewhere, he was somewhere with his family, and I said Devine, I am sorry to bother you on your vacation but we beat Anthem and we really beat them bad.


    So anyway, the bottom line is we, podiatric medicine received the great deal of credit. I actually submitted a resolution to the APMA House of Delegates last year, which said based on the fact that CMA had done it prior to that at their house of delegates saying that -- AMA, I am sorry, the AMA had submitted a resolution saying that there should never be discrimination. There should never be any company that says that we can't -- that an E&M code should be paid for at the same time as a procedure. They should never take away that from us. Especially, if you think about it, if you see a new patient, you got to work them up. If you do a cortisone shot, because you determined that's what they need at that time, you have to evaluate them first. Why shouldn't you get paid for that? Okay. I am not belaboring that. Anyway, alright, so this is also important. It's really important and Rob Lee, we always talk about this and laugh about it that you should look at your EOBs to determine what you are getting paid, whether you are billing appropriately and whether you are getting paid appropriately. So it's important to know what the insurer is paying you for the services you provide. So here is an example of 99213 Medicare pays and this is in Los Angeles. I don't know other areas. Medicare pays about $80; it’s a little $80 and change. Blue Cross pays 72.68, 90% of Medicare, Blue Shield is now paying $80, AETNA pays 63.91, United Health Care pay 67.59, 84% of Medicare and Cigna pays 64.97, although that was 80%. We negotiated with them and by the way when I read in podiatry online whether you can negotiate with insurance companies, you are damn right, you can. You can. If you provide a service that they want and you are good at it and you have value, they will negotiate with you. Even if you are small, I will say on record it's definitely more difficult to negotiate if you are a small practice versus a larger practice and that's one of the benefits of larger practices and that's a whole another lecture. But anyway, the bottom line is we were able to negotiate 100% of Medicare for Cigna.


    I don't know whether any of you have but I am not supposed to tell you that but I told you anyway. Anyway, strapping, here is an example of strapping, which we do a lot. I am a big believer in strapping for lots of conditions and that's another lecture. I am not going go into that. Medicare $39.94, Blue Cross $40.69, Blue Shield $43.14, AETNA $32.07, United Health Care $44.69 So first of all, besides reimbursing at a reasonable level, it's really a valuable diagnostic therapeutic tool and also I think it gives you a -- it's a precursor to determining that a foot orthotic properly made is going to be effective. I think it's the closest thing we have got to properly made foot orthotic. Okay, contracts, real briefly on this because it's a whole another lecture. Contracts, we get contracts across our desk all the time and we are going to get more and more as things go on because things are changing. So it's really important to review your contracts, understand what you are getting paid for, what the value is for being contracted versus not being contracted. You need to know what the cost of doing businesses and you don't make up losses on volume. That's really important comment. Alright, you have to look at the elements of contracts. Again, this is a much longer lecture. Fee schedule but you go to look at fee schedule. You also got to look at ability to get out of the contract as well. That's really important. My wife is a healthcare attorney and told me it's really great when everything is going well but you need to know how to get out it. Very, very important. Okay. Remember, in negotiations if you don't ask, you don't get. Don't be afraid to ask, ask and worse they can do is say no. That's it, in anything. Understand what services you provide and what benefit you provide to the insurance plan. It's outcomes. If you have good positive outcomes and you can demonstrate that and you got patience that will advocate for you that basically say look Dr. X did this for me and I am now walking. Before, I couldn't walk. I was non-ambulatory.


    I mean the bottom line is we want to keep America healthy. We want to keep people on their feet. We want to keep them active and we are good at it. We are the best at it and we are being recognized now more and more and medicine is recognizing us. We are really part of the house of medicine. You know, I have been preaching that since I was president of the state in 2003. We are part of the house of medicine. That's the game folks. That's it. We are part of the house of medicine. That’s the game we play. That's who we talk to. We are no longer ancillary. We are no longer ally. We are no longer any of that nonsense. We are part of the house of medicine. Okay, enough of that. Alright, I am not going to go that. That's contracted versus non-contracted. You can look at that. You have to know insurance companies filing deadlines. If you don't do that, unfortunately, you don't get paid and lot of times you don't have any recourse on that. Basically, they say you have 60, 90, 120 days to pay and you don't file your claim on time, you may get screwed. Anyway, really important, now everybody got high deductibles. We are here in the beginning of the year. We have high deductibles. You got to verify patient's eligibility, you got to determine what their deductibles are and you got to collect at the time they come to you. If you don't collect at the time they come to see you, you are really lost. The problem is you need to know what their deductible is. You need to know how much of it has been met if you can and most of this is online. Most of the time, we verify everybody who comes into the office. We determine what their deducible are, what their co-pay is and we collect at the time of visit because once they leave your office, you have lost. And now you are chasing and then it's a losing proposition. So alright, that's I basically just said. You have to have a strong financial responsibility, collect at the time of visit. The patients need to know what the cost, so we are going into more of a transparency regarding healthcare dollars.


    People want to see actually what things are going to cost and there is going to be comparison shopping. Now, one of the things that people don't realize is that when you are PPO provider, you are contracted. You get basically what the insurance company allows and you can only collect the co-pay and deductible. So even if you bill a $1000 for something that cost $300 and you know they see $1000 but nonetheless you are only going to get paid $300. So it's really important to make them understand the fact that that's the way things are and that's in the hospital too. Okay. I have said that already. I am not going to do that. Okay. Update a fee schedules. You need to be aware of what the fee schedule is. I am not going to go to that. Okay. So we talked about that and I am not going to go through that. Okay. Health Net. So we talked about the 25 modifier issue. So right after Anthem Blue Cross rescinded their policy, Health Net came out through Centene. Centene is a company in Missouri that basically bought Health Net and they came out and said they aren't going to pay for an evaluation management service at the same time the procedure is performed. So once again, myself, the president of CMA, Ted Mazer at that time. He is not president at this time. California orthopedic association, we all met with Health Net and found -- basically we discussed with them the issue that we just did with Anthem Blue Cross and lo and behold, make a long story short, we beat them again. They basically rescinded their policy. So that was Health Net out of the picture. And then United Healthcare in June of 2018 came out with the statement saying that they are going to eliminate evaluation management services at the same time as you did a procedure and again they rescinded their policy. I will get to that. So United Healthcare then came out recently with a statement saying that they are auditing a number of people that "over-bill for 25 modifiers."


    Now, remember we are proceduralist. We do a lot of procedures in the office. We just don't look at people and put them on meds. We do procedures in the office. Therefore, we are going to have a higher utilization of 25 modifiers much like the dermatologist and the orthopedist probably, I mean they are probably of the specialties and the ENT probably as well. Anyway, bottom line is that United Healthcare came up with a company by the name of Change Healthcare and Change Healthcare sent letters to many people, many of us got letters saying that we were over utilizing the 25 modifier. Similar to what Anthem Blue Cross did with their company called Equiclaim. Equiclaim those of you may remember that we got letters from them saying we were over utilizing a 25 modifier and we were over utilizing a level four, level five codes. Well, anyway, I presented that to Keith Greer and Keith wrote a letter to Anthem and lo and behold, they have never enforced that policy. But now, Change Healthcare says that they are going to be looking at our claims and by the way I just was on the phone yesterday with the CMA and their members have not gotten similar letters. So this is strictly now affecting podiatry and I told Keith about that. But CMA told me that in Texas, those guys and girls are getting letters similar to that they are over utilizing a 25 modifier. Their members are getting it, the Texas Medical Association member. So one of the things they say in their letter from Change Healthcare from United Healthcare is that we are here to help you. We are here to help you and this is an educational process but of course it's not education. This is basically something that's punitive, and discriminatory and we are not going to let it go is the bottom line.


    Alright, so I said -- one thing I wanted to bring to your attention is that Anthem was recently noted to be paying for -- on a patient who had surgery and this was actually a podiatrist's husband and they paid. This was at Cottage Hospital I believe in Santa Barbara. They paid for 28285 and 28124 on the same toe. You know what that is 28285 is hammertoe repair and 28124 is partial ostectomy, right, the bone. So they paid the same -- they paid basically for both procedures and the patient complained to Anthem and Anthem said the claim was paid in fact correctly. Now, we have been teaching forever that when you do 28285 you can't bill a 28124 or you can't bill 11750 because it's all part and partial. Well, here we go. Anthem Blue Cross has basically changed their position and I am not going to sit here and tell you what to do but I am just telling you this is a fact. So take that for whatever you want. Okay, Blue Shield. You got to remember one thing, Blue Shield at one time was looking at us as an ancillary allied health, they called us allied health. We have come a long way since those days. That was a long time ago. I can't even tell you when. It was a while ago, but anyway. So I have had a regular relationship with the medical directors at Blue Shield as well and Blue Shield had a policy for fungal nails that basically you had to try ciclopirox before they would pay for anything else. Before they pay for anything other topical antifungal medicine. So I said I am not going to write for ciclopirox because it doesn't work. The studies are out there. Controlled study show it's a 6% effective medication. It doesn't work. The control is 4% effective. So obviously, it's not effective. So anyway, the bottom line is we went round and round for a long time and I spoke to pharmacy and therapeutics at Blue Shield.


    I spoke to the medical directors and the bottom line is now they rescinded that policy and now you have to try, which was really good for us. You have to try an oral medication or find the reason why the patient can't take it besides they don't want to and then they would allow payment for Jublia and/or Kerydin, but they have to either try and fail an oral medication, which is we all know is probably the gold standard and it's probably 80% effective. But there is got to be a reason why the patient can't take it, in fact if they don't want to. Alright, we had problem before we are getting paid for in-office fungal cultures for Blue Shield that we are allowed to do without a clear certificate. I mean we are supposed to have a clear certificate but they never checked on dermatology or anybody else, so I said you can't check on us. If you check on us, you got on check on every freaking dermatologist that does in-office laboratory. And they backed off on that policy. So now we can do in-office fungal cultures and get paid for it. Cigna, so Cigna was an issue where we were not getting paid for strapping. Remember that we were not getting paid for strappings, right, and then Mark Dollard from Virginia and I contacted Cigna Health and I spoke to a woman by the name of Julie Kessel who is the medical director for policy -- senior medical director of policy at Cigna and eventually they were only going to pay for sprain, strain and fractures. They weren't going to pay for plantar fasciitis and posterior tibial tendinitis and things like that. Anyway, the bottom line is we got them to rescind that policy and now you should be getting paid for strapping for plantar fasciitis, posterior tibial tendonitis and such, tarsal tunnel dislocation and other things like that. This is important. So you know we do sclerosing injections for neuromas, right? And so Cigna and Blue Shield are both calling it experimental investigational. They are not paying for it.


    When you have a patient that you want it from Cigna and Blue Shield that want to have -- that you feel is appropriate to give a sclerosing injection, it's cash because they are not going to pay for it. You can bill it as a courtesy but I am telling you they are going to -- unless they miss it, their policy states that it's considered experimental and investigational, it's cash. Orthotics, orthotics for Cigna is the next slide but Cigna and Aetna for orthotics is a very sporadic kind of thing. It's diagnosis driven and so you have to have the right diagnosis and it's different. For Cigna, plantar fasciitis, which is one of the most common reasons why we do orthotics is not covered for Cigna. Posterior tibial tendon dysfunction, however, is, diabetes is, rigid flat foot is and part of leg brace which most of us don't use anyway. So you got to verify with the insurance plan that in fact you have got coverage for orthotics. And Cigna, I mean Aetna is similar. We can't really figure out a set policy with that. Again, I think it's diagnosis driven but what I do is I basically tell the patient this is going to be cash. We can bill the insurance on a courtesy basis but this is your responsibility. And that's what we haven't signed a waiver and explained that unless we have something in writing. Worker's comp, I wanted to tell you that. So I sit on the medical evidence evaluation advisory committee for workers comp. I have since 2010 when it first started and the bottom line is that my responsibility is to evaluate, look at what's called the medical treatment utilization schedule, which just came out again for ankle foot. And we are trying to get folks who take care of workers comp access to this. That's what we are doing right now. But what I want to tell you is you know extra corporal shock wave is not covered by almost any insurance, pretty much but worker's comp, we got them to approve for extra corporal shock wave for refractile plantar fasciitis and now chronic Achilles tendinitis.


    So now that's another condition you can treat extra corporal shock wave, get what's called an RFA, request for authorization approval and then you can actually do shock wave for Achilles tendinopathies that are chronic. There is an MTUS, those of you who do workers comp you should know, you should go online onto the department of workers compensation website and you should actually sign up for the tutorial. The tutorial I think is one CME credit. It's an hour long program and what that does is that gives you an understanding of how to use the schedule because everything is based on the schedule. When you fight with an adjustor and you fight them for approval for a service, you need to know what the MTUS says for that particular condition because you have to be armed with the information. Well, that gives you the information. Okay. One of the things I do want to tell you is that Medicare and this will be addressed I think later on by Paul Kesselman [phonetic] but you know there is a real issue with AFO. This is what I want to share with you. There is an issue with AFOs being called the same or similar policy and what that means is that if you build an L-code anytime with the patient in the past five years and like an L-code can be an ankle brace, it can be an equalizer boot, and then it could be an AFO and you give them one or more of those things, you are not only going to get paid for one and within five years, you are not getting paid for any other L-code including if you give an ankle brace you are not going to get paid for equalizer. More of this will be discussed but what I really want to tell you is I got off the phone yesterday with CMA. I had a long conversation. Anyway, they weren't even aware of it. They aren't even aware of it. The orthopedic community isn't even aware of what's going on. Now, they don't use AFOs like we do. But nonetheless they do use ankle braces.


    I know they use CAM walkers, and they don't understand that if you give a patient an ankle brace, you are not getting paid for a CAM walker. That becomes on you or you can fight with the patient. So it's going to be much greater discussed later on, not by me. Okay, I am not going to go into that. I want to just tell you that Department of Managed Healthcare, Department of Insurance is basically there to serve us in terms of fighting for consumers, fighting for providers. I think I am being given, I think, the yank. Okay. I wanted to just tell you one thing. Clinical data registry. So we should all be signed up for the clinical data registry for APMA because what that does is that gives us ammunition. Remember I said everything is based on outcomes. We need to have data to demonstrate our efficacy, our outcome data to show that we are cost effective providers of lower extremity care. That's going to become more and more important. So every single person in this room needs to sign up for the clinical data registry at the APMA. You all can do it. It's a free of charge. Anybody who is an APMA member, it's free access to you and you can attest to what the MIPS score and you can do it all through the data registry. So very, very important coding. I am not going to go into that except to tell you a lot of us are not coding properly and hopefully that will be discussed later on by my colleagues. But one other thing I want to tell you is -- okay, so I talked about the mandate, talked about that. Okay. So this is really important. Ira Kraus -- under president Ira Kraus, APMA did an incredible thing. He set up a relationship with the AAOFAS with the American Academy of Foot and Ankle Orthopedic Surgeons and the American Academy of Orthopedic Surgery put together a coalition between all of them and now they supported us in our VA Parity Bill. So we now are working together with all the orthopedic community here in California and now being translated nationally. That's huge folks. That's huge. APMA is providing you an incredible service.


    An incredible service besides getting the VA Parity Act passed and now we are hopefully going to get the help bill passed where everybody needs to go on the e-advocacy site and actually sign up. It's very easy. I am really not -- I am technologically challenged and I did it. Very important to write the supporting letters to get the health bill passed. Okay. We need to be 100% invested in our residence's future and this is a whole another discussion. I won't ever discuss this. I am sure Jeff will talk about it later. Anyway, thank you.

    TAPE ENDS - [38:43]