Playing To Win At The Insurance Game

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How To Deal With Orthotic Reimbursement Problems

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.

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Author(s): 
By Neal Frankel, DPM

Who would have thought that when we finally went into practice after years of podiatry school and residency, we would be more dependent on third party payers for our existence than our patients? In fact, recent studies have indicated that, on the average, we spend one-half to one full hour per patient on paperwork and insurance matters. For many podiatrists to whom I have spoken, the “hassle factor” of trying to get paid from insurance companies seems to be the primary reason many of them are not happy with private practice.
Keep in mind this is a game of sorts. The insurers want to keep the money and we want to get paid in a fair and timely manner for our services. However, keep in mind that for every month an insurer can delay its payouts, it can make millions of dollars in interest on the money it still retains. It would be nice for us not to have to pay our rent and other office expenses every month so we too could make money on the money we keep. Unfortunately, we do not seem to be able to enjoy this same luxury.
It is amazing that most of the doctors I lecture to have never even seen the contracts they have with managed care companies and insurers.

Your managed care contract can determine how you are to be paid, when you will get paid and of course, more importantly, how much you will be paid. Many doctors do not even know which plans they are contracted with when you ask them. How can their office know if they are getting paid correctly or not if they don’t even know who is supposed to be paying them? Now many doctors are contracted through IPAs affiliated with their local hospital, but you still are entitled to go in and look at the contracts or at least see what they say.

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