Limited Benefits

Surveys show that fewer and fewer policies provide third-party coverage for functional orthotics. The lack of third-party financial assistance does not negate the fact that functional orthotics should be prescribed if indicated. Patients will pay out of pocket for their functional orthotics. It is reasonable to expect them to be willing to do so once they understand the importance of functional orthotics as well as their financial options and obligations.

Patients’ Rights

Healthcare laws have established many financial safeguards for both insured and uninsured patients. Most of the laws place patients in the driver's seat when it comes to knowing their options when seeking healthcare. Patients can elect at any time not to utilize their insurance benefits. If they choose this option, the provider must offer a Good Faith Estimate as outlined by the No Surprises Act. An insured patient has the right to know about all out of pocket costs up front, and most payer portals are creating robust tools to provide this information to the patient. If a recommended service or treatment is considered non-covered, a contracted provider must consult the payer’s rules for billing non-covered services before passing on the cost to the patient. A patient who is insured or uninsured may opt to join a Discount Medical Plan Organization (DMPO) to manage out of pocket costs for items such as orthotics. When building the clinic’s financial policy, serious consideration must be given to different types of self-pay situations.

Charges and Fees Must be Compliant

It may be considered non-compliant when you have different fees for the same service for distinct types of patients. For example, your published fee schedule for L3020 is $250 per foot, but you wish to extend a time-of- service discounted fee of $150 per foot to uninsured or underinsured patients. This is outside the boundaries of a reasonable time-of-service discount according to the Office of Inspector General of the Department of Health and Human Services. Their guidance has indicated that a 5-15% discount is within normal margins unless you reside in one of the very few states that allow for a slightly larger discount. You have options, though.

Discounts May Lead to a Non-Compliant Dual Fee Schedule

In some states, offering patients time-of-service (TOS) or prompt-pay discounts is perfectly legal. The risk comes in determining how much of a discount you can provide as a prompt-pay incentive. You can’t give patients a TOS discount and then send them a bill. A simple way to avoid dual fee schedules is to join a cash discount network that allows plan members to enjoy discounted fees within your customized fee schedule. One of the most popular is ChiroHealthUSA, a network that allows the provider to set their discounted fees and member patients to access those discounted fees legally and compliantly. If you wish to offer discounted fees for functional orthotics to those without third-party assistance, this is one of the safest and most effective ways to do so. Many states now allow doctors to offer special concierge contracts for services/products, so it’s critical to know your state law.

Medicare is Not Likely to Cover Functional Orthotics

Functional orthotic inserts are covered by Medicare only when placed in a shoe attached to a brace. Medicare’s Durable Medical Equipment (DME) benefit also does not allow for these functional orthotics to be dispensed from a physician’s practice. Functional orthotics for Medicare patients will always be an excluded service under Medicare and you may charge the patient your full fee. Although the rules surrounding the No Surprises Act may not apply to Medicare plans, the intent of the rule to provide advance notice of non-covered services applies to Medicare beneficiaries.

Luxury or Deluxe Orthotics Require Patient Acknowledgement

When the set fee schedule for a covered item is lower than the cost of the item, the patient may be responsible for the difference. Before billing for such items, the provider must consult the payer’s restrictions and/or requirements. In some cases, the payer will allow the provider to initiate the S1001 code (deluxe, upgrade item requested). Whether this code is allowed or not, patient acknowledgement must be obtained before providing the service and passing along the cost to the patient.

Navigating self-pay options requires your practice to establish policies, train staff through scripting, and offer clear financial guidelines to patients. Most of this can be handled by adding a Financial Report of Findings (FROF) to the provider’s Clinical Report of Findings. The next step in this module will provide more information on this process.