Dr. Blake’s recent articles on Posterior Tibial Dysfunction have provided a great deal of clinical information on the assessment and treatment of this condition. These clinical challenges are often accompanied by third-party billing and coding obstacles, interfering with treatment. These are often overlooked and can lead to provider and patient frustration. Let’s provide some keys to success in navigating some of the third-party payer hurdles.
Many patients with PTTD may come to you in pain despite previously having seen a litany of other providers often with a shopping bag filled with failed custom and non-custom orthotics. These frustrated patients tell you that their insurance company does not cover foot orthotics, and they have already shelled out thousands of dollars or that they have already exhausted their coverage.
It is important to have your patient as your ally and have the insurance company as your mutual nemesis rather than the patient viewing you as the obstacle for coverage. Just as patients deserve a careful explanation of their clinical condition, they also need to understand the limitations of their insurance coverage. Hence embracing you as interested in both their medical and financial well-being.
Submitting letters of medical necessity along with clinical notes to the carrier for pre-determination of benefits are practice management tools every practice should adopt. Providing copies of the information submitted to and received from the carrier will ultimately allow patients to understand advanced determinations of whether the orthotics (foot and or AFO) you fabricate will be covered. This way there are no “surprise” bills.
Unlike custom foot orthotics which if self-pay are most often in the $500-$700 range, custom Ankle Foot Orthotics cost in excess of $1,000. Most patients would appreciate advanced warning before committing to self-paying that amount in medical bills. Be sure to ask if they have a Health Savings Account (HSA).
Perhaps the patient will either need a modification of their existing orthotics, or perhaps the patient would be willing to self-pay for the custom foot orthotics. If unilateral, perhaps only one-foot orthotic needs repair or replacement. Any of these can reduce their financial expenditure.
If a CAM boot is implemented prior to receiving a custom AFO, they could be asked to pay for the CAM boot leaving the insurance company liable to pay for the more expensive AFO. Avoiding Same & Similar?
As Dr. Blake suggests, if the patient is to use the AFO for only some activities, it is possible that the third-party payer will only pay for one type of device. Thus, the reason for a carefully crafted letter of medical necessity. Some carriers will not pay for devices needed for sports, but if the patient’s job requires high levels of activity, the carrier, especially if an employer sponsored plan may cover both an AFO and custom foot orthotic.
Conclusion: Every scenario faced by a PTTD patient cannot be explained here. However, both the clinical and billing aspects of treating patients with PTTD can be frustrating to navigate. To achieve success in treating PTTD, practices need to pay careful attention to both the clinical and billing aspects imposed by the carrier.
