Michael Gordon sees Rockville anesthesiologist Bernard Filner as often as weekly for injections into so-called trigger points in his muscles. The shots -- 10 to 20 per session -- relieve Gordon's pain, but they also leave him with big bills. Gordon said he is struggling mightily to have his insurer cover more than a small fraction of Filner's fees.
"Mike [Gordon] is very typical of a lot of my patients," who find that their insurers "say no as often as possible" to chronic-pain claims, Filner said.
If a doctor repeatedly delivers the same treatment to a patient, Filner said, "any reasonable person would think this would lead to the same reimbursement each time." But in fact "there's no consistency" in the charges that private insurers will accept, he said. "What they paid $350 for last year, they want to pay $65 for this year."
Amy Mowles, president of a health care consulting firm near Annapolis, said insurers "are attempting to avoid an overutilization" of trigger point therapy. "When you see charges for $500, I don't blame the carriers for challenging that," especially since Medicare pays what she called a "lousy" $62 per visit or less for trigger point injections.
"It may be that there has been abuse of billing," said Bethesda neurologist Robert Gerwin, who gives many trigger point shots. "On the other hand, one of the major misconceptions in how they set the reimbursement for this is that people think, 'It's a muscle, you just stick a needle in where it hurts and inject and that's it.' . . . A trigger point treatment, properly done, should take 20 to 30 minutes, so it's not like giving a shot of vitamin B12."
CareFirst BlueCross BlueShield administers health plans for about half a million people who, like Gordon, are insured under the Federal Employees Health Benefits Program. CareFirst generally covers trigger point treatment, said Les Chalmers, the company's manager of health care policy. But he added that the standard billing codes for trigger point shots were revised in 2002 by the American Medical Association (AMA), then clarified in 2003, then clarified again this year.
"We do get inquiries or appeals about [trigger point shots] periodically" from physicians who may not have up-to-date coding information, Chalmers said. "While it may be the sense of the physician that he or she deserves additional reimbursement, the AMA is the one that has defined this," he said.
After rejecting many of his 2003 claims, Gordon said, CareFirst changed its stance in May and gave him a stack of checks -- about 20 of them, totaling close to $7,000. Even with that payment, Gordon said, his share of Filner's bills for last year was at least $6,000.
End of story? No.
Gordon said a CareFirst representative told him his 2004 claims will be handled just like 2003's. In other words, he said, "I'm going to have to fight again this year to get my money back."
-- Tom Graham
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