03/29/2017     Keith L. Gurnick, DPM

Denial of Foot Orthotics Despite Doing Everything

Stop letting insurance companies and patients
burn you on getting paid for orthotics.
I have been in private practice since 1982 and
after making every mistake possible and trying
not to anymore, here is how we have refined and
incorporate the financials of orthotics in my
office:

1) If you are contracted with the patient's
health insurance plan, always check benefits in
advance of casting for orthotics.
2) Have a well designed insurance "orthotic
coverage form" with all the necessary questions
and make sure it is filled out completely.

Call the insurance company or go on their
website.
a) my form includes such items as who you spoke
with, day, date, time of call, specific diagnosis
for patient.
b) If orthotics are covered, any exclusions such
as must be diabetic, or PVD, or neuropathy
c) Plan maximum, how many per year, how often,
deductible, met, co-insurance.
d) always get a call reference number and write
it down and save it.
3) Have a well designed "orthotic fees and your
insurance" sheet to give to your patient before
making the orthotics.
a) This might include your protocol for payment
for orthotics, fees, and any explanation of why
you get a deposit and how much.
b) Also, this should include an explanation of
why you can not guarantee any benefits of
coverage based on an insurance call.
( I will include a copy of mine as an attachment)
c) Have the patient sign the bottom and keep a
copy.
4) Almost always (really should
read...."always") get a deposit.
a) Patients who have some skin in the game will
come back to get their orthotics
b) Patients who give a deposit owe less money
when it comes time to pay their balance.
c) Patients who give a deposit will work with you
to help get an improperly insurance claim
reprocessed correctly.
d) Patients who give a deposit, love it when they
get a refund (when the insurance pays and a
credit is due the patient)
e) When you get a deposit upfront, you will have
no problem paying your orthotic lab bill when it
comes at the end of each month.
5) Every Podiatrist should know that Medicare
does not pay for standard custom foot orthotics.
Tell the patient their cash price, get paid 100%
up front on the day of casting and have them sign
a properly designed and filled out ABN or Non-
Coverage Waiver form. If the patient request you
bill the orthotics anyway (maybe because they
think the secondary payer will pay) then bill the
orthotics with the -GA modifier for the denial.

If you are contracted with the DMERC, bill the
DMERC.Medicare and Orthotics
• https://medicare.com/coverage/does-medicare-
cover-orthotics

If you have foot problems, your Medicare doctor
might prescribe orthotics, which are special shoe
inserts. Find out about Medicare coverage of
orthotics.

Keith L. Gurnick, DPM, Los Angeles, CA

Other messages in this thread:

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03/31/2017    Joel Lang, DPM

Denial of Foot Orthotics Despite Doing Everything (Jeff Bean, DPM)

So often, I read of podiatrists having multiple
problems getting their insurance claims paid.
They jump through hoops, spend time on phone
calls with minimum wage insurance clerks and
negotiate fees with patients who are unexpectedly
denied. My advice is not the “ball” in a ping-
pong game between the patient and their insurance
carrier. It is the weakest position you can be
in.

In my practice, I required that orthotics be paid
in full at the time of casting. After submitting
the claim and the insurance paid for the service,
the patient was promptly refunded the amount of
the insurance payment. This was all stated in a
signed release at the time of casting. I realize
that might not be possible in all cases today,
but I have an alternative suggestion.

The Insurance Commissioner in the state in which
you practice is there to enforce coverage upon
insurance companies for which they are
contractually bound. Take advantage of this free
advocacy service. They have a battery of lawyers
who are experts on insurance coverage. When an
insurance company receives a request from that
office to respond to a complaint, they will
definitely respond and their lawyers will not
accept a phony response. When I was in practice,
I actually had a pre-programmed computerized
letter that would allow me to generate a “formal
complaint” with a few key strokes.

When insurance companies know you will complain
to the Insurance Commissioner when not treated
fairly, they will take all your claims more
seriously. When the Insurance Commissioner
receives multiple complaints about a specific
insurance carrier, they will independently
initiate their own investigation. Insurance
companies know that.

Don’t work harder – work smarter. Use your state
Insurance Commissioner.

Joel Lang, DPM (retired), Cheverly, MD