The Reimbursement Path
Clinics must complete the verification process, consult the payer’s Medical Review Policy, and confirm the clinical need for orthotics. Then, it is time to decide which reimbursement path the clinic will pursue - self-pay or third-party pay. Keep in mind all required components of the No Surprises Act and any other federal guidelines when establishing both processes. Listed below is a brief list of considerations for each reimbursement path.
|Insurance Reimbursement||Patient Self-Pay|
|The patient’s medical record demonstrates the payer’s documentation requirements for prescribing functional orthotics.||The patient’s medical record documentation meets minimum state regulations and/or board documentation requirements.|
|Documentation includes essential information to support the allowed conditions for which functional orthotics may be prescribed, per the payer’s Medical Review Policy (MRP).||The practice must offer a Good Faith Estimate (GFE) to include functional orthotics costs if the patient is not utilizing insurance for any service rendered in the clinic or is uninsured.|
|ICD-10 diagnosis codes must match the allowed conditions to the highest level of specificity and point to the functional orthotics CPT (Current Procedural Terminology) ® codes.||When the payers’ definitions of coverage do not include the patient’s condition/diagnosis, the practice must obtain an Advance Notice to Member for Non-covered Services on the payers’ form or their own.|
|Verify that the allowed fee for the functional orthotics exceeds the doctor’s cost. If not, initiate the option to use S1001 code for luxury items, if allowed, with notice to the patient.||When the practice fee schedule for functional orthotics is too steep for self-pay patients, consider membership in ChiroHealthUSA, a Discount Medical Plan Organization (DMPO) network for legal discounts.|
|Code ancillary services, like orthotics management and training, when appropriate, to describe additional work by the provider that is associated with the prescription of the functional orthotics, and expect payment from the third-party payer.||Consider allowing the patient to pay for the functional orthotics and associated services over time. Implement a payment plan that works for the practice and the patient's budget.|