I have a question about shockwave therapy for Musculoskeletal indications (0101T) and for wounds (0512T). Are these covered by Medicare? What about private insurance?
If these are covered now, how do I know if the coverage is pulled later on that I won't be subject to claw backs?
As previoulsy posted by Dr. Freedman, Medicare does not cover shock wave because it considers it experimental. Therefore the code for this is CASH!
As for other carriers, which have a written policy which covers ESWT, if that is the implemented current policy on the DOS, then that is the policy the carrier must abide to, no matter the audit date.
As for what happens if coverage changes, it does not matter when the recoupment attempt starts nor what the policy is at the time of the recoupment. It could be five years or whenever the state statute applies. If the new policy at the time of the recoupment does not cover something, then that applies to the implementation of the policy. What matters is can you succesfully defend that your chart note meets the policy guidelines which were in effect on the DOS.
An insurance company cannot simply recoup money because their new policy five years or more after your DOS does not cover something, but it did at the time the service was provided.
This is true not just in medicine but in our society in general. There is a legal statute and bear in mind I am not pretending to be an attorney, but I have personally used this against UHC and others. It is called ex post facto.
Which essentially means you can't retroactively enforce a new law which was not in place at the time of the incident.
So back to your question, if the private payer provides something to you in writing that there is coverage on a certain date (this could be the written policy or a written pre-determination of benefits for a specific procedure), then barring your failure to prove medical necessity, or failure to abide by the terms of the past policy, you should be able to rest comfortably that a clawback based solely on future policy changes will be unsuccesful.