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Home My WebLink About97-00378 , NOT I C I A USTED HA SIDO DEMANDADO/A EN CORTE. Si usted desea defenderse de las demandas que se presentan mas adelante en las siguientes paginas, debe tomar accion dentro de los proximos veinte (20) dias despues de la notificacion de esta Oemanda y Aviso radicando personalmente 0 por medio de un abogado una comparecencia escrita y radicando en la Corte por escrito sus defensas de, y objecciones a, las demandas presentadas aqui en contra suya. Se Ie advierte de que si usted falla de tomar accion como se describe anteriormente, el caso puede proceder sin usted y un fallo por cualquier suma de dinero reclamada en la demanda 0 cualquier otra reclamacion 0 remedio solicitado por el demandante puede ser dictado en contra suya por la Corte sin mas aviso adicional. Usted puede perder dinero 0 propiedad u otros derechos import antes para usted. USTED DEBE LLEVAR ESTE DOCUMENTO A SU ABOGADO INMEOIATAMENTE. SI USTED NO TIENE UN ABOGADO 0 NO PUEDE PAGARLE A UNO, LLAME 0 VAYA A LA SIGUIENTE OFICINA PARA AVERIGUAR OONDE PUEDE ENCONTRAR ASISTENCIA LEGAL. Court Administrator 4th Floor, Cumberland County Courthouse Carlisle, Pennsylvania 17013 (717) 240-6200 , 2. The Defendant, John D. Reid, D.C. d/b/a Vivo Inc.,is a corporation organized and existing under the laws of Minnesota, having its principal office and place of business at 18 West Main Street, Hayfield, Minnesota, 55940, and is engaged in the business of conservative care technology with a focus on ultrasound devices of the type used by Plaintiff in his business. See Plaintiff's Exhibit 1 attached hereto and incorporated herein by reference. 3. On the 16th day of September, 1995, Defendant sold to the Plaintiff a Model 95 Diagnostic Ultrasound System and extended training to qualify Plaintiff for certification, for eighteen thousand, three hundred, forty-five dollars ($18,345.00), which sum the Plaintiff paid to Defendant. 4. On or about September 12, 1995, Defendant sent a packet of advertising materials on the Spinal Ultrasound System's training and interpretation of the devices to induce Plaintiff to purchase the Spinal Ultrasound System. 5. In those materials, Defendant promised and warranted that the Spinal Ultrasound System met the necessary standards for Blue Cross/Blue Shield, Medicare and other general insurance carriers to cover the examinations, thereby entitling Plaintiff ,.. c...... .,......_ ._.,..~~.~"~",,,,__. . . to payment for examining patients with the Spinal Ultrasound System. See Plaintiff's Exhibit 2 attached hereto and incorporated herein by reference. 6. The Defendant also induced Plaintiff to purchase the Spinal Ultrasound by promising and warranting that all training propagated by the Institute for Spinal Ultrasound Imaging would either meet or exceed the standards of care required by Capital Blue Cross/Pennsylvania Blue Shield and the American Chiropractic Association. 7. In reliance upon Defendant's promises and warranties, Plaintiff purchased the equipment and training, performed examinations utilizing the equipment and submitted requests for reimbursement for examinations to Pennsylvania Blue Shield only to learn that Pennsylvania Blue Shield does not accept spinal ultrasound examinations, that such examinations do not meet the standards of practice in the community, and that Blue Shield's investigation of procedures using the Spinal Ultrasound System indicated that the use of spinal ultrasound is considered investigational and is not generally accepted by the medical community. (Plaintiff Exhibit "3") . 8. Also relying on Defendant's promises and warranties, Plaintiff submitted requests for reimbursement for examinations to Medicare, only to learn that Medicare finds no proven clinical utility as a screening, diagnostic or adjunctive imaging tool and considers ultrasound studies of the adult spine to be investigational and, as such are ineligible for payment by Medicare. (Plaintiff's Exhibit 4) 9. On or about October, 1996, after learning that the Spinal Ultrasound device did not meet community standards, Plaintiff notified the Defendant of the device and the training did not meet the Defendant's promises or warranties, 10. On November 8, 1996 and November 19, 1996, Plaintiff offered to return the Spinal Ultrasound System to Defendant and demanded that the Defendant return the sum of nineteen thousand dollars ($19,000.00), which represents the purchase price of the Spinal Ultrasound System and the extended training program. Defendant failed to respond to either attempt at informal resolution. 11. Defendant's representation and warranties concerning the Spinal Ultrasound System and training constituted warranties {;ltrasound Spinal Scanning & Extremity Scanning SI)rIPLE STR-\IGHT FORWARD A~SWERS TO DOCTORS' QUESTIONS Will [ be paid for my work with this testing technology? The Institute for Spinal t:ltrasound imaging a division of Vivo Inc. has over 17 years experience using the technology and over 7 years billing for tbe technology on an interstate basis. A:s soon as the tirst vertebrAl image was viewed in 1988 Dr. Reid began submitting billings using CPT codes which had been in the A.~I.A. CPT code book since 1985. (The story behind the code preceding the actuality is an interesting one, but too complex for here.) RESPONSE IN 1988 IN "'IN:'oIESOTA WAS 35% IN 30 DAYS WITH THE RE"'AINDER AWAITED FOR IN CASE SETTLEME:'IITS ETC. Since the early research B-arm machine required 5 minutes to image one vertebra the charges were enormous compared to today's fees! Since then percentages of fast response have risen with California reporting 94% positive responses in 30 days, Florida reporting 78% in 30 days. and \linnesota averaging 504% in 30 days and 85% over-all. Our experience with general insurance has been that ~O global policies have been set. thus an adjuster from one desk may pay the full amount. and an adjuster sitting right nnt door may refuse payment. General response percentages seem to rise in States with higher aggression factors in their demographic profiles. \linnesota having low aggression factors would seem to represent the "bottom of the barrel" relative to percentage of cases receiving fast positive responses. Texas, Florida, California. Illinois. Indillnna, Ohio. ~ew Jersey, Arizona. and :"iew York would be e:umples of high aggression factors and consequential good strong reimbursement percentages. Blue Cross Blue Shield generally follows the H:&n'ard Study guidelines ' with even the minima policies :1l1owing 557. for technical and 5045. for professional interpretation. Blue Shield \Iajor \Iedical policies of an upper end nature allow 5250. per re~ion GLOBAL hillin~ with an approximate 511%/511% split permitted hetween technical and professional components lie. 5125. each per re~ion). \-Iedicare follows the Harvard fee for service guidelines: \-Iedical doctor interpretation is usually required at the present time. Radiologist interpretation per se is not noted as necessary for equal opportunity for reimbursement. Chiropractic interpretation is denied coverage by many States Blue Cross 1 Blue Shield Policies. Chiropractic accomplichment of the technical component is fairly trustworthy f~om Sate to State. An Independent ~edical second opinion interpretation is usually a stronger assurance of payment than an inhouse M.D. sign-off. The Vivo 1 Institute program employing independent M.D.'s certified and trained for Senior Reviews and sign-offs results In better percentages and faster turn-a rounds than you might receive if you in- office attempt to interpret your own scans. Good case lego-Medical management is also required with lien fonns available to levy on each case as well as attorney oriented cover letters to aid your positive assurance from the patient's legal representative that your work will be honored in auto accident cases if the third party payer refuses payment initially. Principle #1 THINGS DO ~OT HAPPE:"I. FOR ALL ASPECTS OF PRACTICE YOl' Ml"ST ~KE THE:\'t HAPPE:"I BY WORKING S:\I.\RT AS WELL.\S HARD. THE TECHNOLOGY HAS HAD A CPT CODE SINCE 1985, IT IS USUALLY PAID FOR, A...~D PAID FOR QUITE WELL IF YOU OBTAIN A MEDICAL INTERPRETATION OPINION INDEPENDENT OF YOUR OFFICE. Vivo has independent trained and certified \-tedical doctors avuilable for your use durin~ your initial training. and Vivo also will train any local doctors or Radiolo~ists you may desire to be trained. , t ~ ' In our InterState Services we ohtain an over-\'iew of doctflrs who are winners verses doctors who are not. We see again and a~ain doctors who seem to a"ract and then encourage irresponsihle patients. Any auto accident victim who hus been denied any aspect flf his or her just rights by an insurance carrier and refuses to obtain the services of an a"orney is in my opinion behaving irresponsibly. The ultrasound technology is not a substitute for ~ood sound business common sense. Principle #2 No provider of services accepts le~s than 1000/0 of payment for services provided, why should you be any different? You are worth every cent of your professioal fees, no one else can do what you do. ( had an a"ornev call me the other dav and tell me: " Dr. Smith. Dr. . . Jones, and Dr. Bill are accepting 50% of their fees on this case. would you accept the same percentage Dr. Reid?" (told him ( would accept the same "cut" he had accepted! He responded: "I did not take a "cut" ('m the attorney in the case! (told him my offer was firm. he gets 100% I want 100%. He actually got aggravated at me ! (I later received 100% of my fees plus interest due.) Will I receive referals from attornevs and other doctors for . this service? The big practices like any competitive business know how to promote and advertise. HOW? From what we have observed we must say ANY WAY THEY C.-\.'J DO IT THEY DO IT. From lay lectures to newspaper columns to mailings they continually promote their practices. Too many doctors try a few things and if the results are not immediate they get discouraged and either nit off to something else or stop advenising and stop promoting altogether, THE BIG PRACTICE CLINICIANS STARTED WITH .-\ THOl'GHT: "I'm !loinlt to have a bie. - - -' nch. famous. knO\vn practice," This thought then became their singular goal JIld the means to the enu I u bIg practice I were seized at every opponunity. \j~itht:r Stalt: Bourds, ~rillcisl11 tilr ht:tng too aggrt:sslv~. nor anything ds~ slo\\~d tht:m do\\n. Tht:y \\am~d.\ BIG RICH F.\\IOI;S PR.\CTICE ,md that was the ONE THING in lite that tht:y wanted, I can testilY thut THAT is tht: way to do somt:thing. I wanted tht: public and my colleagut:s to hent:lit via the "St:eing is Believing Practice Style" that I saw was possIble with the ultrasound technology. Itaund the Universe was not EASY, it did not want to change. but I stalled hammering in 1988 at one little point in that solid granite wall known as the Medical-Chiropractic market. [mailed letters, I wrote papers, I talked ultrasound's vinues to every doctor I met, and I kept hammering though tired, kept hammering though discouraged, kept hammering inspite of law suits. Board actions, threats, and all the negativity the professions could throw at me (the Medical and Chiropractic Professions are the most hard of the hard granite Universes). Today we have over 7.000 transprofessional utilizers and the number is growing everyday. IN YOUR PROMOTION OF YOUR PRACTICE THE ULTRASOUND CAN BE AN EXTREMELY VALUABLE FACTOR SINCE NOW YOU Wll.L HAVE SOMETHING FEW DOCTORS IN YOUR NEIGHBORHOOD HAVE AND IT IS SOMETHING FAIRLY EASY FOR LA Y -PEOPLE TO APPRECIATE, YOU WILL ALSO BE EXTREMELY TlMEL Y WlTH THE LATEST (MA Y 1995) READER'S DIGEST ARTICLE ON BACK-PAIN RECO~I1vIE~DlNG AGAINST THE USE OF X-RA YS UNLESS COMPLETEL Y JUSTIFIED. Ultrasound signs of intlammation (which the patient too observt:s on the patient remote T. V,) are a positive objective indicator of damage which the body is trying to repair. [fin your opinion the bio-mechanics of the situation need further investigation via the use of X-ray atter the ultrasound conlinns specific physical injury a large majority (the sane) of patients will agree with your opinion WlTHOUT PROTEST. Salesmanship. patient management. are not needed once tht: patient observes for him or herself the fact that his or her own body is vainly attempting to correct a problem. Will the Ultrasound technology help me reach markets I am not now serving. HMO's and PPO's seem to be invading my area? HivlO's and PPO's gt:m:rally ha"'~ a major !law \\llId\ ~ou \\ith the ultrasound technology can ~mploy to your alh antage, In IlJX') \hnnt:sota seemed to run amuck with HMO fads, As the J....erage Amencan worker was shunted Ill'!' {O HMO IUt:at grinder care llound my practice engaged tht: long lerm pain sufli:rer. most were managt:rs and dirt:ctors of companies. it:. wealthy individuals who had had pain lor more than 6 months and at that point Jid not care WHAT THEIR INSL'R.~i'iCE COVERED THEY WANTED RELIEF AND \VERE WTLLING TO PA Y FOR IT. Tht:se types ofputients came from near as well as far (flew in from i'iew York. Chicago. Los Angeles. and most of the States of the 50 States) and paid cash tor an examination and follow-up treatments. If you are prepared to handle difficult puin problem patients the market is extremely strong, PRINCIPLE #3 The hard pain market is always there waiting for someone with something new that might afford them relief or at least hope. Unless a National Health Law makes it illegal to accept their cash YOU can always have a booming market. and with the ultrasound technology and also the "Blossom Effect" plus the real time capability lor "Peek and Treat" you should do very well IF YOU MAKE IT HAPPEN BY LETTING PEOPLE K~OW WHAT YOU HA VE and how to reach you, The most fun is granting relief to a senior insurance executive and watching how fast that third puny payer check arrives! Terms: "Blossom Effect" An accelerated healing effect based upon monitoring tissue reaction to physio therapy in real time using the ultrasound scan technology to cenify efficacy of a maximal degree has been obtained. "Peek and Treat" The techniques involved in monitoring tissue changes pre and post adjustment with high resolution ultrasound scan technohzv (Vivo ~lodel97 or 95), ~. Will I be paid by workcomp? I personally have found that ever slIlce the psychological srudy which re\ealed that J worker l.lut of \\ork over ell) Jays 'EVER RETL'Ri'iS TO any son l.lf .:mployment the game tor work comp IS "Getlhem back to work." Since with the ultrasound :ican [echnology I can Ji rti:rentJate physical from psychological better than cver before ,\~D TI-IE;-J \IUI\ ITOR fHER. \Plr:~ ,-\S APPLIED PHYSICALL Y ',\hile mtelligently :1Jllressing the psychological I can kill the average statisticai return [0 work time lor any givcn condition on a ten to onc basis. 1 make no humble pie about:: 1 gctting the worker back to work tcn times faster. #'2 cxplaining that the ultrasound was an intrinsic part of the process. #3 alTering to avoid using this m:w exciting precise diagnostic adjunctive in the future on any workers covered by a given insurance company if they really do NOT want to pay for it (and/or explain all this to the President of the company the worker came from) and IF I TRUL Y GOT THE WORKER BACK TO WOR'<. IN BLAlINGL Y FAST TIME I GET PAID THE FULL ULTRASOUND CHARGES EVEN [F [ EMPLOYED IT EVERY SINGLE DAY. The funny thing is that Ultrasound Orthopedic scanning was specifically out- lawed in the work comp regulations in Minnesota in 1993 (some mis-guided "expen" apparently). This aspect was repealed in 1994 and actually entered into the Minn. Chiropractic Association Standards of Care as an acceptable diagnostic. [like to think it was because of my brazen blazingly fast statistics and the way I promoted it all. but I will probably never know for certain. Principle #4 Money talks and nobody walks ! lnspite of even Laws occassionally passed by people with uninfonned prejudices against anything new if you can demoQstrate cost etfectiveness with a high degree of patient satisfaction and get the worker back to work ten times faster than anyone else YOU WIN. tenns: physical: Anything of an intlanunatory reactive nature indicating real injury and :ieveriry of injury, psychological: An~1hing else: E.\ample: Om: worker with minimal physical :iigns of inflammation on scan but maximal expressed pain kept "harping" on how he was taken off his machmlstJob md made to :iweep the shop e:vet:'day at 3 P:Vl. I e:mphaslzed hiS value as a fmher to his children. his value as a husband to IllS \\lle. his value: as qUlle :ilmply a person with sk1l1s md interests away from his "job statton" pt:r st: and how prnhahly his "\'loss" JUS! had him ,;wcep tht: !lour because ht: \lhe workcr! was the nicest guy In the shop ~md the \'loss respt:cted his "service :,mitude" and knt:w he \ the worker-father-hushand- man I wouldn't mind helping out with a Job that simply had to be Jone. One treatment session and back to work full time full duties the next day! From antalgia and grimacing with t 5 degrees forward t1exion to full duties and pain free over- night! Total cost to employer's insurance $295. including the ultrasound fee, Example #2: Patient revealed "bright star" nerve entrapment sign to the right of L5 on scan but no inability to toe walk or heel walk. Expressed pain +4 grade right sciatica with lightning shots exceeding +4 and inability to stand for longer than 1 hour at work. M.R.l. con tinned a failed spinal operation with residual instabiiity at L5 and disc fragments impinging on the sciatic root slightly PLUS collapsed disc spacing L5/S 1. Work supervisors kept pushing for:2 hours on the lint: with 1/2 hour rest. Patient seemed to be failing under this pressure from his supervisors BUT WIlli NO remarkable change on the scan images as time progressed, Muscle spasms were increasing, antalgia was worsening, ability to stand straight was failing to a 15 degree forward llexed continual posture. In discussion while physical treatment was rendered I mentioned the reason his supervisors were pushing him so much was that patients tend to NEVER RETURN TO WORK IF THEY STAY OUT OF WORK longer than 90 days. so !-.is supervisors were EXERCISING TOUGH LOVE PSYCHOLOGY TO TRY TO SAVE HIM. FROM THAT F ATE! I will testi fy under oath that his posture straightened at least one full inch and 15 degrees within minutes alter I said those "right words", He is still in pain today. but he smiles occassionally. the muscle fibrillations have ceased. and his antalgia is gone A01"D HE IS WORKING THE FULL TWO HOlRS AT A TIME WITHOUT COMPLAINTS. The nicest thing is that I was not guessing, I knew approximately his range of physiologic abnonnality. the psychological was "everything else". Will Sports Injury Patients with no secondary gains psycho logy benefit? Sports Injury pati~nts in my ~xp~rience have secondary gains of an inverse nature \vhich often ruins the cas~ unless - th~ magic of the ultrasound technology is available. - -~ :\5 verses the average work..;omp patient. the Sports Injury patient desires to get back to the game so hard that he or she otten ruins your good work through breaking of discipline or pushing too hnrd with rehab exercises etc. On a management basis there is nothing like "Seeing is Believing" (that little patient remote T. V, which we package with each system) to help hold management tirm BUT we also have to ask ourselves How did Nancy Kerigan get back on the ice in 7 days after being bashed in the knee with a metal pipe? Imagine > Being able to watch the tissues react to each therapy as applied and K.1"\fOWING what to watch for for maximal healing induction (we'll teach you). This is the way you dreamed Sports Healing would be, but with ultrasound scan technology with high enough quality and resolution those dreams could be NOW. Imagine > Being able to monitor tissue reactions to rehab exercise and controlling inflammatory reaction to rehab with a micro-scopic precision to know precisely how much "push" you can allow without signiticant ~xacerbation. With ultrasound scan technology you can make every dream come true and tinally practice the way you have alwavs desired. low stress. high success. in a .. . - . quality assured environment of "S~eing is Believing Practice Style" within a net\vork of trans professional coll~agues all speaking the same language of S~rvice and Success. I ! r , , 1 I' I P.02 . ., Pennsylvania B1ueShield C".aml1 HUI. P,nnlylvania 17089 4It1lld.~.............."" ...c_ "".... ......-....cw... CERTIFIED MAIL RRTtJRN RR~r:TPT REOl~STP.n December 3.1996 I Thomas J. Smarsh. D.C. Smarsh Chiropractic 3599 Old Gettysburg Road Camp Hill. P A 17011-6802 Dear Dr. Smarsh: Pennsylvania Blue Shield operates under the provisions of Act 271 of 1972 (40 PA C.S.A. Section 6301 et seq,). Section 6324 (c) of the Act requires that all matters. disputes or controversies relating to professional health services rendered by health service doctors. or any questions involving professional ethics. shall be considered and determined only by health service doctors selected in a manner pl'C$Cribed in the By-Laws of the professional health service corporation involved. Article X. Section 2. of Blue Shield's By-Laws stipulates that a Medical Review Committee be formed to consider, act upon. dispose of and determine all controversies arising out of the relationship between Blue Shield and professional providers who render health services to the corporation's subscribers. The Medical Review Committee currently consists of eleven doctors of medicine. two doctors of osteopathy. one doctor of podiatry. one dentist and five consumer representatives. The Members of the Medical Review Committee wish to express their appreciation for the information you provided at the n.eeting on November S. 1996. After reviewing all available Informadon, the Commltt.. d.termln.d thot there IQ no 'UPportlns data In lAd.xed Ne....,! scientific or cllnk~l profM~ionJll jnllmRl~ tn ~lIpport the ll!ICflllnCll~ of ultra.~ollnd of the IIpine. el(cept when used intraoperatively or in neonates, The Committee also noted that the quality of real.time diagnostic ultrasound is vel)' dependent on the experience and tralnlni of the peraon operating the equipment and interpreting the studies. They concurred with our consultant that the quality of your studies is questionable due to your limited training and your need to have your interpIl:taUollS oVtmc:llU, Iu iil!u.ilivlI. the Comuuttee determined that you routinely unbundled ultrasound of the $pin.. anti inRppmpriRtely reported it under multiple procedures in an effort to maKimize )'our reimbursement. Based on the.e determ;".tiolUl. the ,.,^......Ittee. with only the Professional Members voting. moved. seconded and CAlTied that no payment be made. for these services. . P.03 . " ... -2- As a Paniclpating provider with Pennsylvania Blue Shield, you have agreed to abide by the Regulations for Participating Provider.. Regulations 6, 9, 10 and 13 of Section B of the Regulations for Participating Providers state: A Participating Provider pcrfonning covered services for a Blue Shield subscriber shall he fully IUId completely responsible for all statements made on IIllY claim form ~ubllliltw W Blu\: Shic:lu with l~pc;"'L Lv ~u",La $0:1 viCC$, .cglU'dlcS$ or the moue Qf execution or verification of such report which may be accepted by Blue Shield. A participating Provider who misreports services to Blue Shield shaH be responsible for reimbursing Blue Shield for all payments which were caused by such misreporting, The determination as to whether any covered service meets accepted standards of practice in the community shall be made by Blue Shield in consultation with providers engaged in active clinical practice. Fees for covered services deemed not to meet accepted standards of practice shall not be collected from the subscriber. A Participating Provider shall render covered services in the most cost effective manner and in the least costly setting rcquixN for the appropriate treatment of the subscriber, A Participating Provider shall bill Blue Shield for covered services performed for Blue Shield subscribers only if such services arc medically necessary. The determination as to whether any covered service is medically necessary shall be made by Blue Shield in . consultation with providers engaged in active clinical practice, Whenever payment criteria related to cost effectiveness or medical nccesslty arc developed, they will be made available to Participating Providers in Blue Shield's professional publications. Fees for covered services deemed not medically necessary shall not be collected from the subscriber, unless the subscriber requests the servicc(s), and the Participating Provider informs the subscriber of hislher financial liability and the subscriber chooses to receive the scrvice(s). The Participating provider should document such notification to the subscriber in his records, The determination as to whether any services performed by a Participating Provider for a Blue Shield subscriber are covered by a Blue Shield Agreement and the amount of payment for such services shall be made by Blue Shield, If you have any questions concerning this matter, please contact me at (717) 763-3207. Sincerely, . ~~/Y1' I G. ; - C . (J~"'ff Eme~e A, Sconing, Manager U Benefits Utlllzation Management EAS:dla . -..... , Pennsylvania BlueShield Camp ltill. Pennsylvania 17089 ,,"~L~olNl"'c-...III.teIl\llllll"""_ MAR. 2 6 199B CIlRTIFIIlD MAIL RIlTURN RIlCIlIPT RIlOUllSTIlD Smarsh Chiropractic 3599 Old Gettysburg Road Camp Hill, PA 17011 Dear Doctor Smarsh: On October 18, 1995, we informed you that we were reviewing spinal u1trasounds which you report under procedure codes 76536. 76800 and 76880, Subsequently, we requseted copiee of office records and ultrasound scans for a listing of patients and advised you that they would be forwarded to a professional consultant for review. That review has been completed and enclosed you will find the original u1trasounds that you forwarded for review. The consultant stated that the superficial ultrasound examinations. as well as the technique in general, are of poor quality, inappropriately and grossly overbilled and with no scientific support in either the chiropractic literature provided or in medical literature. Section B.9 of the Regulations for Participating Providers states as follows: The dotermination as to whether any covered service meets accepted standards of practice in the community shall be made by Blue Shield in consultation with providers engaged in active clinical practice, Fees for covered services deemed not to meet accepted standards of practice shall not be collected from the subscriber. The quality of your ultrasound examinations has been deemed inadequate. Thus, it does not meet the standards of practice in the community. Therefore, no payment will be made for future services of this nature. A copy of the consu1tant's opinion and the Regulations for Participating Providers are enclosed. I would also like to take this opportunity to provide additional information on Pennsylvania Blue Shield's position on spinal ultrasound. We have been reviewing this issue for sometime, In order to do this, we searched peer reviewed medical literature, obtained opinions from our consultants in radiology, orthopedic surgery, neurological surgery, and chiropractic. We also contacted state and national professional societies concerning the efficacy of the ultrasound in study of the spine. Our search of the peer reviewed medical literature yielded nothing to support the transderma1 use of ultrasound in the adult spine. USA Q%) .-- IIIt_lolll....." l".."....~ ...~.......,".....I- 1 '.10....._ I..... , , ,..., ''',,.41 Smarsh Chiropractic Page Two Available studies predominantly refer only to intraoperative and neonatal applications, In addition. the consensus of opinion from the individual consultants and professional organizations queried. overwhelmingly agreed that ultrasound of the spinal and paraspinal tissues, the spinal canal and contents is a modality that should be considered investigational and not generally accepted by the medical community. The exceptions to this would be ultrasound studies of the spinal cord when performed intraoperatively and in cases of children under one (1) year of age. Based on the information received from the aforementioned sources, the Medical Affairs Committee has recommended that Pennsylvania Blue Shield consider ultrasound studies of the spine to be investigational and, as such, ineligible for payment except for the evaluation of the spinal cord, either intraoperatively or when the patient is under one (1) year of age. If this is approved by the Board of Directors, we will then notify all providers of our position on this issue. We are providing this information since it directly affects the services in this review. If you have any questions concerning this information to this issue, please do not hesitate to contact me. (717) 763-3207, or anything related I can be reachsd at Sincerely, Grc\JQJ~' Emelie A. Sconing ~ Manager Benefits Utilization Management Ilnclosures ,. , .. . ~t~~;t/t;:b:, ,~t,!,:;l.,,,,..;,...~;;' ':--.,h\,. ~, -, !l,-r,";"~;;'IN'. ~ ':"". ~;fl/f'^f,;:-.'.",~ f,~ '~"''\.;,'.~'i':~iij,;/" ~~~~' ,~-',{:}}f '1';"," ""~'fj.i.; '~{'~~Kf-.~'~;;"~' . ~..,~"...,., 'l~{;'/ :Y~'{~"~ ",:<r~'ll 1;;i" '., '~~'i;:~n-:h~~\,~i r",,'" ~_..",.\:{,... ""',_1' .';~\l:{~:'~'~".,:7: ':: ::.~'. (':;;'1~I .,......f:...r...,..t. " -;:'r ., .' . (",1 Pennsylvania ~ l;lu~Shic,ld c,mp Hill, Pnnl)ll"lnla 1'7089 _ -.................. _..... e.............................- CERTIFIED MAlL RIITURN RF.CF.IP.T RF.QIJF.STF.n December 3, 1996 Thomas], Smarsh, D.C, Smarsh Chiropractic 3599 Old Gettysburg Road CampHilI,PA 17011-6802 Dear Dr. Smarsh: Pennsylvania Blue Shield operates under the provisions of Act 271 of 1972 (40 PA C.S.A. Section 6301 et seq.). Section 6324 (c) of the Act requires that all matters, disputes or controversies relating to professional health services rendered by health setvice doctors, or any questions involving professional ethics, shall be considered and determined only by health service doctors selected in a manner prescribed in the By-Laws of the professional health service corporation involved. Article X, Section 2, of Blue Shield's By-Laws stipulates that a Medical Review Committee be formed to consider, act upon, dispose of and determine all controversies arising out of the relationship between Blue Shield and professional providers who render health services to the corporation's subscribers. The Medical Review Committee cllIIently consists of eleven doctors of medicine, two doctors of osteopathy, one doctor of podiatIy, one dentist and five consumer , representatives. The Members of the Medical Review Committee wish to express their appreciation for the information you provided at the meeting on November 5, 1996. After reviewing all avallable /.... information, the Committee determined that there is no supporting dataJ!!.j'p'<!~lt.~~~ced vi scientific or clinical professional journals t~I1_!!l~~~l\e~:u~f.WI!~_W}~..~f the ~.ine, ~=e'p.!.. whe~,~d i~.9P,!;r~\iy"ly.Rti~Jlj:Qn~~.~..}he Committee also noted that ilieqiWityof real-time diagnostic ultrasound is very d~pendent on the experience and training of the person operating the equipment and interpreting the studies. They concWICd with our consultant that I) the quality of your studies is questionable ~!le. to yo~ "~i!~ tr8;in!.ng and y.,?~ ~!O ~~;.;j:! your inte~~.~~~E~_9X!:..rr.e.~;_..1n addition, the Committee determined that you' roiilliiely Uiibu-ridlea ultrasound of the spine and inappropriately reported it under multiple procedures in an effort to maximize your reimbursement. Based on these detenninations, the Committee, with only the Professional Members voting, moved, seconded and carried that. no payment be made for these services. ( I. , f , r. r, ~. ',;'. l~, , " ~, . . ~ ",. .. '. ~ n . . . ..;.0#" . Medicare :, . (;. :~ !. P.0"> dol' .,. ~ .., .'.1.... . )(act .....10.,. l'h'lCt' ort A Quarterly Newsletter for Medicare Providers , , h'1'Iidl' . . , .. "4'J . MediCAl DIrector', MeuAse ...,...... 5 " ..j . ::~ Electronlcally SpoaklDS ' ,. ".:: ii ." EMC New, ........................,........_ 4 '; EMCAdvantagc, ......................... G , Policy NewIRe\i,ed ............._................. 8 Clarlned ...................................... 19 .j Relrllburscment.............,..............lD"j . i.:,~ Specially News ":I Ambulatory Surgical Centers.. 3~ ; Cblropractlc ..........,....,............... 55 i Durable Medical Equlpm~nt.., n:'J Palllology .................................,.. 55 'j , .>.'./ ~ ':'.::t News .............'................................... S4: : '.~; Claim lIeporllnA' Tips ..,................ 411 '. ...1 Audio nesponse Unll Card ....IDurl, ! . , ", ":11 ,':.' ....,.~ ~ ,,:~! ...;j ,( : " i December I DOG , . Cover Story " Audio ResponJe Unit Improved " Our Audio Response Unit (ARU) has been improved as a result of feed. back from health care professionals. The ARU will now provide more informalion and easy.to.follow dlrCCllons and prompts. , . The enhanced ARU offers: . claims stalus information and reason for denial. , 1 . the number of claims pending and finalized weekly . check information relating 10 specific claims . most recem check information on file" . month and year.to.date earnings.. . current fee Information for procedure codes . validation of a diagnosis code for a procedure code . Informational messages on frequently ,equested topics There is no holding time and you are able 10 access information on an unlimited number of claims, TheARU Is now available through our regular provider service lines Monday Ihrough Friday, between the hours of 8:00 AM. and 8:00 PM. DC Metropolitan Area Delaware New Jersey Pennsylvania 717.731.2333 717-731.2333 717-975-7050 717.763-5700 . All calls for claims status information will be serviced through our ARU, To receive Information on your accoun15. you will need the pro. vider identification number (PIN) of the billing provider. .. In order 10 receive earnings and recent check information, you will need 10 enter the ZIP code of your practice in order to validate your provider identification number, }l(;l~CS C\ld~~ 76600 E~hography, spinal canal and contents 76986 Echography.lntraOperaUve HCFA's National PolitY N/A Indications nnd I.Imltatlons of CoverBl!e The use of ultrasound in studies of the spine has limited medical application. However. ultrasound can be effec- tively used as an intraoperative Imaging device. When used in this manner. the transducer Is directly applied 10 the sp,nal cord or to sterile fluid infused directly around the cord. Ultrasound may be used 10 localize an other. wise non.apparenllesion of the cord or the surrounding areas 10 the depth of the cord. for surgical biopsy or reo pair. Spinal ultrasound can also be used prenatally to detect meningomyeloceles. The transdermal use of ultrasound In the adult spine for the evaluation of pain or radiculopalhy syndromes (facet joints and capsules. nerve and fascial edema. and other subtle paraspinous abnormalities) currently has no proven clinical utility as a screening. diagnostic, or adjunctive imaging 1001. Covered Icn.9 Codes N/A {teasons (or Noncoveraee Transderma\ ultrasound studies of the adult spine (76800) are considered to be investigational and as such, are In. eligible for payment, ~oncovered ICD-9 Codes Any ICD.9 code reported for transdermal ultrasound stud. ies. 16 .$p,~,!.<;~,.l!!.lnt!lt.roll t\oU Medical Affairs Committee Board of Directors Consultants in Radiology. Orthopedic Surgery. Neurological Surgery and Chiropractic American ASSOC. of Neurological Surgeons; Section on Pediatric Neurological Surgery American ASSOC. of Neurological Surgeons and Congress of Neurological Surgeons: Joint Section on Disorders of the Spine and Peripheral Nerves American Chiropractic College of Radiology American College of Radiology DelawareAssociatlon of Neurological Surgeons Delaware Society of Orthopaedic Surgeons Maryland Neurological Society The Neurological Society of the Virginlas New Jersey Institute of Ultrasound in Medicine New Jersey Orthopaedic Society Pennsylvania Academy of Chiropractic Physicians Pennsylvania Chiropractic Federation Virginia Chapter of the American College of Radiology Xact Medical Director Vice President. Medical Affairs Codini Guidelines Transdermal ultrasound studies are to be reported using code 76~00. The use of other codes to report transdermal ultrasound studies of the adult spine is not appropriate, Procedure code 76986 should be used when reporting intraoperative ultrasound. pocnment8tlon Reoulrements NlA Other Comments N/A ., ~AC Notes This policy does not reflect the sole opinion 01 the car- rier or Carrier Medical Director. Although the nnal de- cision rests with the carrier, this polley was developed In cooperation with the Carrier Advisory Commiltee which includes representatives from radiology and orthopedic surgery. MEDICARE REPORT I DECEMBEI\ tDD6 '- , - ,.... S~" Medlc~rc M~dical l'ollcy Rulletln L.l concerning pap ,mears, Also, see Medicare Medical Pulley Bulletin X.21 for in. (ormalion on mammography. CAC Notcs The policy was developed prior to Ihe formation of Ihe Carrier Advisnry Comminec, and the mand~led 4S.day ,~omment Jleriod. S1Prt Date IIf Commcnt Period N/^ &art Date orNotl,c Period N/^ Ji:ffective Date 01/20/97 Revision DlIlc ,... N/A Revision Number V.24B Tumor Marker CA27.29 Tumnr marker CA27,29 is a radioimmunoass~y (RIA) invltro diagnostic device il\dic~ted for use in serum or EDTA plasma of palients previuusly treated for Stage II or SlaKe III breast cancer. Effer,llve for servi,es performed nn or after January I, 1':197, cuvcrase Is provided fm CA27.29 when reported (nr munit,,,ing Slage II or Stalle III breast cancer palients (or the dCll,ction of recurrent breasl cancer. Use procedure code 66316 and lhe descriptor CA27.29 along wilh one of the following appropriate ICO.9 diag. no.is codes 10 report this service: 174.0.174.9 Mallgnanl Neoplasm o( Female Bre..t -- Ml>me^Rv. n~:POI\1' / DI>CF:MREl\ 1996 Mali!'.nant Neoplasm o( Mal~ Bmall. Nipple and Areolae M~liB'1ant Neopla.m of Male Breo<I, Other and Un.pecl(ied Sites Secund~ry Malignant Neoplasm o( Brea.t p'!lSonal History of Mallgn.nt Neo. plasm, Breast When reporting code 8b31 (, (or any olher tumor marker, please Include a descriptor to Indicate which lumor marker you are performing. - . 175.U 17S,'J 1':18.61 vl0.3 Ultra,ound TherapY for TMJ Effective for services performed on or aller ,anuary 20, 1997, ultrasound therapy (970)5 - application of a mo- dality to one or more areas; ultrasound, each 15 mln- ules) is eligible lor paymenl when performed for lhe treat. ment of temporomandibular jointlTMIl dysfunction. Uhrasound as a diagno.tlc tool remains noncovered for the dlal\nosis ofTM) since ills not 01 proven value. There. fore, procedure code 71>536 (echography, soft tissues of head ancl neck (e.g.,lhyrold, parathyroid, parotid), B scan and/or real.time wilh image documentation) will be de- nied as investillallonal when performed (or TM). Ultra,ound of the Spine (X-30) This policy Is effective (or services performed on or afler January 20,1997. pescrlptlon Ultrasound utilizes sound waves by very high frequency, which cannot be detected by lhe human ear. Such waves penelrale tissue, bul some tissues will reRm them more than olhers. The sound sourca is combined with a sensl. tive microphone which picks up the pallem of reflected sounds and converts them 10 a visual display 00 a tclevl- sion screen. HCPCS Section Beneftt CatlljorY Radiology 15 '. . .. . r' ,-., -I 1 , , . ~ ~ .,-; . ~ - Ot J i\:) 1.1: ': -, G " , , ) k 1 "- , I~ ~ , I r _ ,l "'l .h ., ) ,''1 0 .' ,'.' ", ~ ~ ~ :., ~.;~ . , 'u ", .. ~ U ~ ~ ~ u., '> ~ ~ ""- -.t.. 1 n -I s: 1.1 I~~ - jklil...oJ" - 9, Afj \ I I... 11.u...... &1<-..'[; <;/';/'/'17 f 0 .0 ~ C -I .- "'1'" ". .-.1 Cui;;, r= 'r: /.. ~ I I :;, 111:0 ,;":.1. N J~ C- " 0' j",' ~) !:;(, 2:': ;:J , . ..;;( ,'- i,j ~. r- '? )>c: ~ ~ :,.,) ~ \0 t A. f. r -h:l"'" ~ ..." f( (, :' .fJ VERIFU'ATION The undel'llillned. ,John I). Rl'id. hl'rehy Vl'rinl'sand stlltl'S that: 1. He Is the President 01' Vivo Inc. a rellular Minnesotll Corporation with numerous stockholders: 2. He has been named as a derendant in the within action: 3. Vivo corporation has been named as a derendant in the within action: 4. The racts set rorth in the roregolng "answers" are true and correct to the best or his Imowledge and backed up by corporate documents on me as well as the exhibits set rorth by the plaintllT. 5. He is aware that any raise stlltements here in are subject to the penalties or 18 P.a.C.S.A. {s}4904. relating to unsworn ralsificatlon to authorities. 2/15/97 .John ~ ~~) re: DR. THOMAS SMARSH d/blaJ SMARSH CHIROPRACTIC. PENNSYLVANIA PlalntllT IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY vs. JOHN D. REID. D.C. d/b/aJ VIVO INC. Docket# q, - ') 7 ~ Re: Derendant Civil Action at Law ANSWER TO COMPLAINT hv Derendant Ir the court nnds the rormat or the enclosed "answer" disnlelL~lm! or unuseahle we resnectrullv reQuest time l.rtension 01' 60 davs to re-liIe an answer In accentllble rormats and stvles: Respectrully submitted; .-\S representin!! himselr & the Corporation. '.. ~ . /. - / "- I /'. ( /), {~ hn D. Reid (Pres.) Vivo Inc. P.O.Boxl116 Hayneld. Minnesotll 55940 2/15/97 Dr. Smarsh verses Vivo Inc. Complaint Answer 2 otLgs We hold as true that Dr. Reid lIS President of Vim Inc. and as Senior Scien.;e Mediator or Vim quality Assurnnce Services. l\mctloned in relationship to Dr. Smarsh as a potential buyer and then buyer of Vivo products lIS an otncer of Vivo Inc. We thus feel the complaint Is wrongfully directed as naming Dr. Reid lIS a private citizen as enjoined in the complaint's direction. The Medical Ultrasound System purchased was purchased from Vivo Inc. not rrom Dr. Reid as a private seller. 1. c. Vivo's address Is: Vivo Inc., P.O. Box 1116. 17W. MaIn St. Hayfield, Mn. 55940 1. d. We petition the court to dismiss the complaint as directed toward both Dr. Reid and Vivo Inc. and Instruct the complalntant's attorney to re-dlrect per his discretion. 2. Please rerer to #1. above. answer is the same: 3. Vivo Inc. sold the device system: 4. The advertising material as exhibited was part of a total sales eITort, and only part or the total eITort which Involved many aspects of presentation of advantages for a professional spine care healing arts doctor to own the device system. 4. b. INTENDED USE: The Medical system was sold as a functioning ultrasound scanner intended for soil tissue Imaging of any/all body tissues Including spinal and parasplnal tissues. A long history of scientific use of ultrasound scanner systems being employed ror these purposes In the United States over at least 20 years preceded this sale. The system was an ultrasound soil tissue scanning system and was In no way presented primarllv lIS a pront center. money making scheme, nor In anyway presented In an Imbalanced way as regarding ree gleaning verses services delivered for the benent of patients. We feel the complaintant has ertrncted trom Vivo's balanced literature as presented to the complalntant prior to and at the time of purchase (over 500 pages of sclentlnc and other materials) the rew Items related to money reimbursements and misrepresented them out of context in an attempt to support his noxious unethical and unproressional complaint 5. :'tlo warranty or payment by insurnnce carriers or ror payment by insurance carrters as indenntlely carried unto the future was made or implied: 5. b. Vivo's Reliance in these matters orsales is that Vivo sells Proresslonal Medical systems not consumer items to lay persons: 5. c. Vivo's Reliance in these matters orsales is that doctors are the target or sales eITorts and that doctors are nroressionals involved In matters of public trust 5. d. Vivo's Reliance in these matters relating to sale ora Medical system Is that whatever nrofessional audience Is the recipient orlnformatlon trom VIvo or Its represenmtives. is indeed a professional audience with balanced attitudes and concerns ror sclentlnc basis. utility basis. service to patient basis. and reasonablll expectation of I 2/15/97 Dr. Smarsh verses Vivo Inc Complaint Answer 3 ot---1-Pgs: bein!! paid by patients as primarily responsible !'or payment of fees I'or services. Usual and customary healin~ arts proressionals as recipients or informatlun about the ultl'llSOund technology and systems have as part or their concern probability 1'01' payment or rees by health insurers ur health assurance companies such as BeDS at the time or purchase such that patient direct fee payment responsibility is partially relieved. These monetary concerns however are usually only nart of their concerns as being encloaked in the doctors' proresslonal concern ror the well-being or their patients. 5. e. Vivo's Reliance in these mattel'll or sales additionally is that recognition orthe delimitation of any human agency as dlITerlng trom an omni-potent or omniscient transcendental agency, Is anticipated so that statements relative to insurance companies paying rees are relied upon by potential purchasers in a reasonable sense as historical statistical summaries and that no predictions about the future can be made since: 5.1'.-#1 Vivo Inc. iS'llot an insurance company: 5.1'.-#2 Vivo Inc. does not set the policies nor sit on the boards or any Insurance companies: 5.e.-#J Insurance companies generally rely upon cost eITectlveness and other statistics as well as the general economic tone of II given region as the future develops and insurance company policies, terms or policy, and reimbursements rates have often changed historically and thus are recognized by reasonable people as subject to change as the future develops. 5.1'. Usual and customary indicators ror payment probability at the time or purchase are: 5.1'.-#1. A history or previous payments by various insurers as well as health assurance companies involved In the business of insurance such as BCBS. 5.1'.-#2. Certified Procedural Technology codes (C.P.T. codes) ethically utilizable with such codes approved by the American Medical Association. 5.1'.-#3. The age and history or the CPT codes up to the time or purchase. 5.1'.-#4. Published Federal Medicare rates ror the services associated with the technology at the time of purchase. 5.1'.-#5. Other similar professionals in the same geogrnphlc region who report payment ror services associated with the technology on or about and also prior to the date of purchase. 5.1'.-#6 We hold that at the time or nurchase or the ultrasound system by Dr. Smarsh D.C. the above nve usual and customary indicators were available ror review and that copies of the related documents are on me proving no misrepresentations were made In that payments ror services associated with the technology were being paid by various insurers as well as BeBS of Pennsylvania (a health Assurance Company Involved In the business or Insurance): 5.1'.-#7 Copies of checks are on me trom diverse insurers as well as health assurance companies Including BCBS or Pennsylvania. showing payments or up to $125. per region ror the services associated with the technology. . . 2/15/97 Dr. Smarsh verses Vivo Inc Complaint Answer 4 of.2-P9S: 5. f.-#8 Copies and originals 01' the \9112 and \ 9115 CPT code bOIlk.~ are on nil' revealing valid coding as approved by the AIV1A since 1982 ror extremity scanning and since 19115 ror neck and spine scanning (with extremity scanning continued as valid), 5.1'.-#8 (please review above in light of "age or codIng validity") "(Copies and originals of the \ 982 and 1985 CPT code books are on tile revealing valid coding as approved by the AMA since 1982 for extremity scanning and since 1985 for neck and spine scanning (with exttetnity scanning continued as valid)." 5.1'.-#9 Copies or published Federal Medicare rates for the services associated with the technology at the time of purchase are on me. 6. No wamntee relative to A.C.A. (American chiropractic AssoCiation) policies or decisions was rererred to since Vivo Is a trnDSproresslonal company selling systems to Medical as well as Chiropractic doctors and Vivo relies upon A.M.A. CPT code guldellnes and not.on dtclaratlons or policy positioning by the A.C.A. since historically the A.C.A. has always rollowed rather than led the healing arts proresslonal associations In general. Specifically the A.C.A. has approDmatley 7,300 members In a profession of 55,000 pracUcioners and does not represent nor set policies for the majority or doctors of Chiropractic. Ultrasound spine and soil tissue scanning utilizers presently number approx\tnl1lely 7,000 utilizers, both Chlropractlcally and Medically, and thus ultrasOund ror orthopedic diagnostic purposes is almost as powerful a rractlon of the healing arts as is the A.C.A. per se. Vivo thus considers the A.C.A. Inconsequential In the general scheme or polltlcal. financial, and healing arts policies setting. 6.b EDliCATION AND TRAINING: We note that Dr. Smarsh never completed hts training program and thus "training with Certification" and the value or lack or value ror same should not be an issue. We note that Vivo Inc. through The Institute ror Spinal UltrasOund Imaging (a division of Vivo Inc.) oITered to Dr. Smarsh extended training with certification so that his service to his patients would be as excellent as possible: Our Intent was to establish quality utilization standards and unlronnlty which at the time of urchase of the s stem was bein received favorabl b BCBS re resentatlves for BCBS of Pennsylvania. We note Dr. Smarsh rejected the extended training activity as soon as Dr. Reid runctioning as Senior Science Mediator for Vivo Quality Assurance Services criticized Dr. Smarsh's report writing as not being within the Standards of Care and Pathology Signs Recognition Standards as set by The Institute and as originally taught to Dr. Smarsh during his ciass-room work under Dr. Reid's proressorshlp through the Institute. The specific instances are on me in Dr. Smarsh's training file, and shoW patient scans In which Dr. Reid Is of the opinion no significant pathology Is demonstrated and in which Dr. Smarsh has written reports claiming multiple slgnlflCllJlt pathologies are demonstrated which might Indicate significant need for care under his auspices. Dr. smBrsh railed to present Images with any dlscernable reatures. Dr. smarsh then wrote outlandish reports ciaiming multiple and serious pathologies Indicating need ror care, .-\Iler this dual critique Dr. smarsh railed to present evidence of reports moderated according to Dr. Reid's sugRestlons. failed to submit any I\lture reports to continue his training proRrnm, and never received certification nor any confirmation of . .,-, ........._~'- -~.._' . 2/15/97 Dr Smarsh verses Vivo Inc Complaint An ;wer 5 otLpgs' his intellectual abilities to interpret nor accomplish even un the technlcal level Ilood practice ultrasound scan examinations. 6c. We note Dr. Reid Is the United States Patent holder ror nerve root Imaging with ultrasound scan technology and copies orthe granted patent are un me. We note Dr. Reid had experience since 1988 scanning patient spines with ultrasound technology and had been teaching and interprettlng other doctors' (student's) scan images of patients trom all across the USA since 1992 and had trained well over 150 doctors and technicians to the time or Dr. Smarsh's rejection or the extended training program. We note that Dr. Smarsh had owned his ultrasound system ror mere weeks and had presented a rew dozen Image sets up to the time or his rejection of the extended training program and Interpretation quality assurance. 7. No warranties relating to future payment, nor future behavior of BCBS or any other insurance carrier were ever made. See answers to #S above please. 8. No warranties relating to ruture payment, nor ruture behavior or BCBS or any other Insurance carrier were ever made. See answers to #5 above please. Additionally, under law the patient Is primarily responsible ror payment or fees ror health care services. IrDr. Smarsh was in a special "Provldershlp" status which barred him rrom collecting rrom patients directly any unpald balances he should have exercised due diligence and conrerred with his "Provldershlp Advisory" people berore purchasing or engaging technology which may have been treated dlITerentlally by reason or his . . "provldershlp" status with a given Insurance carrier. 8.b. We also note that X-rays are not paid for by Medicare If they are accomplished by a Doctor or Chiropractic, but are traditionally and customarily paid for by the patient. . Thus if Dr. Smarsh as a doctor or Chiropractic Is treated dlITerentlally by Medicare or any other insurance carrier Dr. Smarsh had the responsibility to conrerence with his BCBS or Medicare" Advisory" rererence people to discern his special status positioning and then make a decision as to purchase or non-purchase or the system or any diagnostic equipment We must question whether Dr. smarsh is making legal complaint agalnst his X-ray equipment company due to the ract that Medicare does not pay for Chiropractic X-rays. We must question why whatever procedure is rollowed to recoup fees ror X-rays Is not also being rollowed ror recoup or reI'S ror ultrasound scans. and why ultrasound diagnostic imaging should receive dlITerential prejudice and legal complaint compared to X-ray diagnostic imaging by Dr. Smarsh? Please rerer to #5 above. re: documents on file giving Medicare rates for the ultrasound service as scanninll spine.neck. and extremities. , . 9. We do not remember nor have evidence ror this conversation: Please refer to # 6b above relating the reasons involving unethical useage and non-amenabl1lty to trnining and quality as.~urnnce standards: "The specinc Instances are on nIe In Dr. Smarsh's training me. and show patient scans in which Dr. Reid Is of the opinion 110 slgnlncant pathology is demonstrated and In which Dr. Smarsh has written reports c1aiminll multiple sillnincant pathologies are demonstrated which might Indicate ."...."'...--... ..-. . . 2/15/97 Dr. Smarsh verses Vivo Inc. Complaint Answer 6 of..2...Pgs: ~lgnlrlcant need for care under his auspices. Dr. ~mal'1lh railed to present imDlles with lInv d iscernable features. Dr. smarsh then wrote outlandish reports claiming multiple and! erlous pathologies indlcatinll need ror care. Aner this duai critique Dr. Smarsh railed to present evidence of reports modernted lIccordinll to Dr. Reid's suggestions, failed UI submit any future reports to continue his trninlnll program. and never received certincatlon nor any connrmatlon of his Intellectual abilities to Interpret nor accomplish even on the technical level 1l00d practice ultrasound scan examinations. Il 10. Not true: VIVO'S OFFER REJECTED: Upon being initially notined orDr. Smarsh's dissatisfaction with his "used" and months old machine s)'!ltem, and being Interested In seeing the technology removed trom Dr. Smarsh's questionable auspices, without Vivo admitting of guilt or any wrong, Vivo made oITer to the plalntlf1's attorney that Vivo would represent Dr. Smarsh on the used machine market place and attempt to sell his machine system ror a reasonable used machine system price 01'$14,500. taking no profit per se, but a minimal reasonable handling and inspection fee. as rrom the buyer's side of the Interaction. VIVO'S OFFER REJECTED BY SMARSH'S ATTORNEY AND VIVO REJECTION OF THEm COUNTER OFFER: Dr. Smarsh's attorney replied to Vim with the rollowlng summated demands: #1 That Vivo Inc. purchase the machine system ror the stated price sight unseen using pre-payment with no assurances or condition nor bond orre-saJeablllty. #2 That this act of reckless abandon ofaJl sound business principles be committed by Vivo before December 14th, 1996. .' We relt the attorney's demands were an unreasonable set or demands possibly masking a hidden agenda on the part orDr. Smarsh, his attorney, or both and thus Vivo did not bother to respond to Dr. smarsh"s attorney's response. Vivo being Involved with the Intensities of business, training, publications, and other usual and customary activities. The attorney's unreasonable response to Vivo's initial oITer. is on me with the attorney's letterhead etc. 11. Not true: Please see #5 and #6 above. We are appalled by this doctor's singular emphasis on monetary gains, failure to be properly trnlned. and apparent view orthe technology solely as a money making method with no regard ror the value or interpretntlon reports and clinical "added value" ror the benent or his patients who look to him for valuable healing arts services with positive social impacL No warranty was ever explicit or implied that undisciplined use with no added value would result In assured future amiable reception of fees by any Health Care Fee Payor whether private or as representing a third party payer. 12. We reject this summation in its totality: Please rerer to all preceedlng answers: 12-a. The complaint is misdirected: 12-b. Warrantees or future payment by any/all Insurers were not Implied nor explicitly stated since: 12-b.-I. Patients have the primary responsibility for health ~'lIre rees payments. 2/15/97 Dr Smarsh verses Vivo Inc Complaint Answer 7 ot-Lpgs: 12-b.-2. Vivo is not omniscient but a human allePl:Y and cannot predict the I'uture. 12-b,-3. It is a ract that payments \VerI' being consistantly received hy Vivo and its clients rrom many insurance carriers at the time Dr. Smarlh purchased his system (Including payments by BCBS or Pennsylvania). 12-c. Vivo relies upon a balanced proresslonal attitude on the part or recipients of sales materials since Vivo sells Medical Systems to Doctors who generally uphold the honor of their public trust Vivo nnds Dr. Smarsh's sole concentration on prol1ts and monetary matters unusual to the point of being socially and proresslonally noxious and embarrassing to the profession or Chiropractic and possibly representing a danger to the public good. 12-d. A universally accpeted American principle of commerce Is "value given for value received." Dr. Smarsh's expectation that he, as an untrained operator and an untrained interpretation report composer, should expect payment by patients or Insurers for his valueless services we think violates this American principiI' and enters into the realm of "legal complaint that the complalntant could not commit fraud toward insurers and patients unimpeded". 12-e. We petition the court to dismiss the complaint ror all the reasons arore stated here and above and to make complaint Itself to the State Board or Chiropractic requesting Dr. Smarsh's general practice modus operandll be re-examined. and also to make comp!alnt to the Attorney General's office State of Pennsylvania to have Dr. Smarsh's billing practices audited for signs of fraudulent billing, dlITerentlal charges, or other 1JIegal prnctlces since we nnd it highly suspicious that Dr. Smarsh when raced with Insurance rejection of whatever rees does not simply b1Jl the patient directly, and we rurtheJ:.nnd It suspicious that Dr. Smarsh though untrnlned in any aspect of the technology is complaining that his bills for services involving his untrained use and interpretatlo!, ~r nndlngs were not paid by insurers. 12-1'. We also petition the court ot Investigate why our oITer to re-sell the device system on the used equipment market is now presented in the complaint as "Ignoring-no response" and thus wonder if Dr. smarsh's attorney railed in his duty to present our offer to the compialntant, thus unethically attempted to induce dispute and legal complaint to earn undeserved rees, and thus attempted to burden the court's already heavy schedule with an unnecessary and unethically through non-disclosure induced lawsuit. Respectrully submitted; As representing hlmselr & the Corporation: ohn D. Reid (Pres.) Vivo Inc. P.O.Box 1116 Hayl1eld, Minnesota 55940 n '..:;I (") r:- -.l -n ~., .." ;i .,." ;" ,-', '...') ;;~ :;,;'- ~J .'~n ll! Ui -~6 , . '......\ ,- -u .' !\'."") "-. ,co . '..~' .'1 ~.) ,. :..0 .IJ -< r' , " Pennsylvania BlueShlcld Camp Hill. Pennsylvania 17089 M~l~ol..BltACIt>....-lDoweSnottcl.ltON_ Milfl. 2 6 1998 CERTIFIED MAIL RETURN RECEIPT REOUESTED Smarsh Chiropractic 3599 Old Gettysburg Road Camp Hill, PA 17011 Dear Doctor Smarsh: On October 18, 1995, we informed you that we were reviewing spinal ultrasounds which you report under procedure codes 76536, 76800 and 76880. Subsequently, we requested copies of office records and ultrasound scans for a listing of patients and advised you that they would be forwarded to a professional consultant for review. That review has been completed and enclosed you will find the original ultrasounds that you forwarded for review. The consultant stated that the superficial ultrasound examinations, as well as the technique in general, are of poor quality, inappropriately and grossly overbilled and with no scientific support in either the chiropractic literature provided or in medical literature. Section B-9 of the Regulations for Participating Providers states as follows: The determination as to whether any covered service meets accepted standards of practice in the community shall be made by Blue Shield in consultation with providers engaged in active clinical practice. Fees for covered services deemed not to meet accepted standards of practice shall not be collected from the subscriber. The quality of your ultrasound examinations has been deemed inadequate. Thus, it does not meet the standards of practice in the community. Therefore, no payment will be made for future services of this nature. A copy of the consultant's opinion and the Regulations for Participating Providers are enclosed. I would also like to take this opportunity to provide additional information on Pennsylvania Blue Shield's position on spinal ultrasound. We have been reviewing this issue for sometime. In order to do this, we searched peer reviewed medical literature, obtained opinions from our consultants in radiology, orthopedic surgery, neurological surgery, and chiropractic. We also contacted state and national professional societies concerning the efficacy of the ultrasound in study of the spine. Our search of the peer reviewed medical literature yielded nothing to eupport the transdermal use of ultrasound in the adult spine. USA Q%) 'Ill~ '.111.."10 l~..""". ~I..'"'' ,of Ih. I....... "'''''''1.-'''''' , Smarsh Chiropractic pags Two Available studies predominantly refer only to intraoperative and neonatal applications. In addition, the consensus of opinion from the individual consultants and professional organizations queried, overwhelmingly agreed that ultrasound of the spinal and paraspinal tissues, the spinal canal and contents is a modality that should be considered investigational and not generally accepted by the medical community. The exceptions to this would be ultrasound studies of the spinal cord when performed intraoperatively and in cases of children under one (1) year of age. Based on the information received from the aforementioned sources, the Medical Affairs Committee has recommended that Pennsylvania Blue Shield consider ultrasound studies of the spine to be investigational and, as such, ineligible for payment except for the evaluation of the spinal cord, either intraoperatively or when the patient is under one (1) year of age. If this is approved by the Board of Directors, we will then notify all providers of our position on this issue. We are providing this information since it directly affects the services in this review. If you have any questions concerning this information or anything related to this issue, please do not hesitate to contact me. I can be reached at (717) 763-3207. Sincerely, ~t-~ C \6<:J n Emelie A. Sconing : / Manager Benefits Utilization Management Enclosures I it. m g to ~ o ~ .... \ ~I ~ ~ ~ --~ p o \1\ ;n ~' (~"l') :; ~\ ......, ~ ~ ~ J:J: 8 ~ UlUl ~~~~ ::!!::!!oo( 0U)a::a. ~g ~i~g~ i~ ~<lllm ~ j!:.J:Ju ~f o~z ........ s! ':.: .a: ~ ~ .. a:< u g~ t.O OU w ~ ~ ljt rn t'- 0 ~ - I rn ,- .. .w rn , f ! 0 :0< . . ':.: " "... ..;",.. , 'I Hayfield Spine Care & Spine Diagnostic Center P.O. BII.I: 1116 /layfleld, MIl. 55940 r f Phone (507)477-2544 Fax (507) 477-2278 Date: 7/14/97 To:Abeln Law Offices Attn: Gregory Barton Abeln. Esquire 37 E. Pomfret St. Carlisle, P.A. 17013-3313 IN THE COlJRT OF COMMON PLEAS ClIMBERLAND COUNTY,PENNSYL VANIA II 378 CIVIL, 1997 Re: Arbitration hearing "Smarsh Vrs ,John D. Reid D.C. dba Vivo Inc."(sic) Dr. Smarsh purchased an ultrasound system from Vivo Inc. a regular Minnesot<t'C" corporation with approx. 32 stockholders: This corporation is a separate entity legally rrom Dr. Reid D.C. and thus the "dba" in the complaint rormat is confusing to both Dr. Reid and Vivo Inc.. Additionally Vivo Inc, as a corporate entity is an FDA registered corporation for sale of Medical devices under 510K and PMA. whereas Dr. Reid has no such registration. and thus is precluded by Federal regulation rrom such activities. Thus Dr. Smarsh did not purchase the ultrasound system rrom Dr. Reid, but did purchase the system rrom Vivo Inc. Dr. Smarsh's baseless and precedentless complaint seems directed rather fuzzily making derense impossible since the diretion is oriented toward a chapter S situation or sole proprietorship which Vivo Inc. definitely is NOT. Until such time as the complaint cn be re-directed properly both Vivo and Dr. Reid must reject the arbitration process in favor or court proceeding where the claimed plaintiff can be rorced by process to properly direct. We are confident that in a fair jury situation any group of reasonable people will find Dr. Smarsh's "complaint" unreasonable since: III An interstate used equipment market exists, thus if the machine system is In good condition it should sell easily through any used equipment dealer: 1#2 Vivo has offered to broker the machine system but the terms proposed by Smarsh's attorney were unreasonable and conducive to further dispute: (Sight unseen purchase by Vivo ror resale with delivry or payment prior to inspection was proposed:) ~ . Hayfield Spille Care & Spille Diagnostic Cellter P.O. Box //16 Hayfield. Jill. 55940 Phone (507)477~2544 Fax (507) .471-2278 Date: 7/14 /97 To:Abeln law Offices Attn: Gregory Barton Abeln, Esquire 37 E. Pomrret St. Carlisle, P...\.. 17013-3313 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTy,PE:"INSYl VANIA 1# 378 CIVIL, 1997 Re: Arbitration hearing "Smarsh Vrs ,John D. Reid D.C. dba Vivo Inc,"(sic) Dr. Smarsh purchased an ultrasound system from Vivo Inc. a regular Minnesotti'C" corporation with approx. 32 stockholders: This corporation is a separate entity legally from Dr. Reid D.C. and thus the "dba" in the complaint format is confusing to both Dr. Reid and Vivo Inc.. Additionally Vivo Inc. as a corporate entity is an FDA registered corporation for sale of Medical devices under 51 OK and PMA, whereas Dr. Reid has no such registration, and thus is precluded by Federal regulation from such activities. Thus Dr. Smarsh did not purchase the ultrasound system rrom Dr. Reid. but did purchase the system from Vivo Inc. Dr. Smarsh's baseiess and precedentless complaint seems directed rather ruzzily making defense impossible since the diretion is oriented toward a chapter S situation or sole proprietorship which Vivo Inc. definitely is NOT. Until such time as the complaint cn be re-directed properly both Vivo and Dr. Reid must reject the arbitration process in favor or court proceeding where the claimed plaintiff can be forced by process to properly direct. We are confident that in a fair jury situation any group or reasonable people will find Dr. Smarsh's "complaint" unreasonable since: 1#1 An interstate used equipment market exists, thus if the machine system is in good condition it should sell casily through any used equipment dealer: 1#2 Vivo has ofrered to broker the machine system but the terms proposed by Smarsh's attorney were unreasonable and conducive to rurther dispute: (Sight unseen purchase by Vivo for resale with deiivry of payment prior to inspection was proposed:) - - Shumaker Williams:p.c. --- - ^1111I.1!.~;. ".,IAW -" -- IiltllH" 0'" t'......O~".. ,..."." IIlDAUI nail"" _OCR lo\llMJfC( W CW;ut HIOIOt.AlBTtlU. .1ft J STCvt'" liMo II'" ....IM' W W()A"IION ,Nfpt()flj,. J JOse.. .101..0 lIH1C',!l.DY I*,IO H UAUCHI' .",IH. (,;W"'flltl IIUftNT C u.-w ~YN [I ~ lUUIOr.. J ll\w.Q ......-.."."....,-... ........_.,.,._....._....w....... M"'....." If." """"-""'" ~lG'fl"" H'" tnUHC)lotf' Inll JU.t12'l IN'AnINQ.pt.....,....,.,. rlLlI'ttONl ,,,,,...... rAW 11m "JHII !W, 00,,",'01 "...tn........ 1UUtOC ,"4) """,n 'U,I'41D1rtM M'I""IJ'~~ IMn"lOl February 12. 1997 -..... "~,,,"'''''l. Prothonotary's Office Cumberland County Counhouse One Courthouse SquaI'C Carlisle, PA \7013 Re: Smarsh v. Reid Docket No. 97-378 Our File No, 353-96 Dear Sir or Madam: Pursuant to your request, I have enclosed the orialnal Return ~ indkatlna tIIII the Defendant in the above-referenced matter was served with Plaintiff's Complaint via Certified Mail Return Receipt Requested. Respectfully submiued. SHUMAKER WILUAMS. P.C. I lit {br.l p feu.<<.~-L. By Carolyn D. Kaminski CDKlkcs: 68037 Enclosure fH" "ltHN5VIYA",." ,:rNrcn :\111ft ....."IQN ....Akr MnAO CAlM' HIU..I'I!......".... ...." 44.... n''lLLCnC MlCNU" h:\"t HO 1Ii,^" (;O"'.,c... "INNIY\WM tHat .' , " ,,' '. r'\ {-"","'C PLE.I). '.,~~~,'.~:.~;,,'~J n" C'F "". 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