As insurance companies look to reduce their services or payments, they have looked to orthotics as a way to cut costs. Since many plans do not acknowledge or truly understand the importance of orthotics in treating many foot conditions, they have unfairly denied payment on them or have routinely listed them as not medically necessary for conditions that would usually require prescription orthotics.
However, by following a few simple steps, you can usually get your orthotic claims paid without delay or denial.
Initially on all patients you would expect to require an orthotic, you should do a routine pre-authorization prior to casting the patient. When you call the plan, ask if there is any restriction on coverage for prescription orthotics. Sometimes a plan will list the orthotic under a “foot device” similar to an over-the-counter arch support as a way not to have to pay for it. Make sure you get the plan’s representative to state the exact wording of the coverage restriction so you can appeal this determination to get an approval before you make the devices. Many insurance companies have particular protocols (which would determine medical necessity) for orthotics listed on their Web site.
In my capacity as the Co-Chairman of the Insurance Committee for the Illinois Podiatric Medical Association, one of the most common problems I have seen is no documentation in the medical record of the patient having any pain after his or her initial treatment by either injection, taping, etc.
If the patient were symptomatic when he or she came back for re-evaluation, then why would he or she need a custom orthotic? It is very important the medical record substantiates the need for a custom orthotic and that some other conservative treatment was performed prior to deciding on an orthotic. I will always include a “letter of necessity” form letter, which includes the criteria as listed by the plan as having been met with my actual claim. This usually will get the claim paid promptly with very little requests for documentation one month or two after my claim was submitted.