Gather the Facts
Some patients’ insurance may cover functional orthotics, but more often, there are caveats to consider. Many payers are moving to a model in which all Durable Medical Equipment (DME) must be dispensed through an in-network DME Supplier in order to be covered. Some require that the prescription for the DME is only valid when ordered by an allopathic physician rather than a Chiropractor or other type of provider. Therefore, it’s critical to verify all insurance coverage thoroughly, asking all the right questions, to determine whether the patient’s benefits include functional orthotics. Be sure to check with each individual carrier as well as your state scope of practice that may require a spinal-related diagnosis, an extremity-related diagnosis, or both.
A Thorough Verification of Benefits
As with all aspects of Chiropractic care, a simple verification of coverage is never enough when dealing with orthotic coverage. Simply asking or reviewing whether a patient’s benefits include orthotics can leave a gaping hole in the information required to receive payment. For that reason, a multi-step process is recommended to protect the practice and the patient before ordering functional orthotics.
Follow these steps for success.
- When– Verification of benefits can happen before your patient comes in. You can copy the orthotics verification template page and place it on the back side of your existing verification form. Collect necessary information on the intake phone call and pre-verify benefits. For practices that scan every new patient, as recommended, verify orthotic benefits right along with other chiropractic benefits. Then, if functional orthotics are ordered, you have all the information necessary to bill and collect properly.
- What– To get all the answers you need, specific questions must be asked in a very specific way. For that reason, we’ve supplied a template verification form for your use. The questions on this form are carefully curated to guide you through the potential land mines associated with orthotics billing. We urge you to follow the form exactly, adding additional questions as they may relate specifically to your office.
- Where– Reviewing an online benefits portal is probably not enough to get you all the information you’ll need to bill orthotics. Basic coverage information is rarely sufficient to help you know all the nuances that may be in play. We urge you to always check for the Medical Review Policy (MRP) for Orthotics and Prosthetics on the Payer’s website. It will delve into the specifics of which diagnoses are covered and under what circumstances orthotics are considered medically necessary.
- Why– Once you have reviewed that MRP, investigate the patient’s specific benefits. The form will direct you to questions such as the allowed fee per foot, which codes are covered, co-insurance percentage, and additional ancillary services that may be covered. This deeper dive is important to arm you with all the information needed for successful billing.
So, what happens if your investigation reveals that the patient doesn’t have full insurance coverage for functional orthotics or the patient’s diagnosis is not consistent with coverage? This happens quite often, but it doesn’t mean the patient’s needs change. Now is the time for the provider to prescribe, regardless of coverage, and as with all care, have your teamwork with patients to make the orthotics affordable within their family budget. The next page explains some options for self-pay patients.