Identify the Patient Portion When Shoes Are Involved

Frequently, patients have coverage for medically necessary orthotics from their third-party payers. As with all care submitted for reimbursement from carriers, coverage for orthotics is provided according to the medical review policy of the carrier. Often, this is where you’ll find the diagnosis codes that are covered, the requirements for coverage, and other important details that ensure you are submitting only the services for which you can be reimbursed.

When coverage is provided for orthotics, and medical necessity is established, you may decide that the best fit for the patient is an orthotic that is imbedded in the shoe. It’s never appropriate to bill a third-party payer for the actual shoe unless coverage is provided. Often, the shoes are only covered for certain diagnosis codes or conditions (e.g., Diabetes), and often, these shoes must be prescribed by an MD which may limit the availability for coverage.

So, what happens if a patient does have coverage for orthotics, and the best fit for the patient is to prescribe Sandalthotics®, Shoethotics® or custom flip-flops products in which the functional orthotic is built into or provided with a shoe. Or, what if the patient is purchasing shoes with custom orthotics, even if the orthotic is removable because the shoes are used daily for work? While the orthotic may be deemed medically necessary and therefore potentially “coverable” through the third-party payer, it’s unlikely that the shoe would be covered. In those instances where there is coverage, it is appropriate to bill the carrier for the orthotic and bill the patient separately for the corresponding shoes.

The scenario might look something like this:

The patient purchases a pair of Naot Sandals with built-in orthotics. The total charge for the sandals with orthotics is $300.

If the patient were purchasing only the orthotics in your office, the fee would be $210. In this case:

    • The patient pays $90 out of pocket for the shoes.
    • The payer is billed the $210: L3020-RT—$105 and L3020-LT—$105 (per our usual orthotic billing protocol).
    • The medical record indicates that you dispensed the shoes with the custom stabilizing orthotics for the condition, diagnosis, and treatment plan.
    • The billing summary shows that the carrier was billed ONLY for the orthotics and that the patient paid cash for the shoes.

Providing options for your patients that include shoes can be a wonderful cash profit center for your practice. Even if orthotics are not a covered service, their necessity, for spinal pelvic stabilization, is clearly in conjunction with your chiropractic treatment. You are encouraged to consider orthotics for any situation where the spinal condition could be exacerbated by a postural imbalance. Orthotics have been shown to specifically reduce low back pain and can improve posture and the effectiveness of the chiropractic adjustment. Consider orthotics as part of your treatment plan, and if it makes sense for the patient to purchase shoes with the orthotic, use this simple and effective method to bill properly and collect your fees.