AFO not in scope
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A colleague recently contacted me that a state carrier denied his claim for an AFO because it was out of scope. He requested some information on how to respond.
With the limited information provided, please find my response:
Without having more specifics, such as the patient's diagnosis, HCPCS codes and what state you are from its kind of difficult to provide an exact answer. However, going on the assumption that the state scope of practice does in fact include the diagnosis for which your patient has a documented diagnosis, one can provide a general answer. One must also assume that the carrier did not require prior authorization, referral to a subpanel to provide this service, credentialing, etc. That is the following comments are limited only to the state scope of practice:
Let's assume the patient has a documented diagnosis of a posterior tendinosis which is located only in the foot, below the malleoli and solely at level just proximal to its navicular insertion.
Again assuming that the rejection is solely based on your scope of licensure:
The recommendation is to write to your state podiatric medical association. Most likely they have an insurance committee (I am a member of the NYSPMA Insurance Committee) who would review the pertinent information (PHI redacted). Depending on the specific carrier, one approach may be to have a representative of the insurance committee (or the state society’s lobbyist) contact the carrier’s policy writers or carrier medical director.
Failing that, the insurance committee may recommend the state association submit a letter of inquiry to your state podiatric board. The state board would be asked to determine if prescribing and or dispensing an AFO for this specific purpose (or for what purposes) is within your state scope of licensure.
The state board's answer would then be directed to the state podiatric medical association and not to the individual physician or carrier. That answer could then be submitted to the insurance carrier via an appeal.
If the insurance carrier is mandated to cover services under your licensure (Medicare and Medicaid are), then the services should be reimbursed on appeal. Also state law may mandate coverage for anything covered under your state scope of licensure.
It is NEVER in the best for the individual provider to contact the state podiatric board for a decision. This should be left to the discretion of your state association. Why? It is always possible that the state board would provide an adverse decision, should your documentation be insufficient. The resulting adverse decision by a state board could have far more negative consequences and be more difficult to overturn.
Allowing cooler heads to prevail, the medical directors of the insurance carrier will not feel that you went over their heads to achieve a favorable decision. I learned this thirty or more years ago the hard way, with a surgical situation, where the state board admonished the carrier. And while ultimately it resulted in a favorable decision for my claim(s), it did result in some rather hard feelings from the carrier’s medical director directed toward me.
The lesson learned from my indiscretion is to take the longer more objective approach. Allow the system set in place for your state society’s logistics to handle this. State components usually have people in place who have good relationships with the medical directors and/or policy writer at the insurance carrier. Failing that a positive response from the state board directed to your state society provides an objective response which can be forwarded to the carrier.
