- July 11, 2022
- Posted by: Steve Smith
- Category: Orthotics Billing
Understanding Insurance C0overage in Orthotics Billing
In the realm of Orthotics billing, the range and variety of items covered is an extensive one. It is a long list comprising items such as back braces, cervical halos, knee braces, orthopedic shoes (with leg braces), arch supports, toe separators, custom built shoes and countless other devices of many different kinds, with new variants being added regularly. Most health plans provide coverage for a large number of Orthotic devices and supplies. However, there are some that are excluded. It is important to understand which items are excluded from coverage in order to prevent unpleasant surprises later on.
By a rule of thumb, non-custom items, especially those which can be procured over the counter and are intended to provide comfort rather than treat, are usually not eligible for reimbursement under a health plan. For example, external accommodative, digital, and supportive foot orthoses are seldom covered. This is chiefly because such orthotics are flexible or semi-rigid devices and are used to ease foot pain, rather than correct the condition. As such, they are considered comfort and convenience items and are excluded from coverage.
More Coverage Caveats you Should be Aware of
Speaking of podiatry items, orthopedic shoes are usually not covered except extra-depth orthopedic shoes that are used to prevent or treat diabetes-related complications. Orthopedic shoes are covered when attached to a leg brace. Similarly, non-custom made or over-the-counter shoe inserts or arch supports are generally excluded from coverage. However, special footwear meant for use in case of foot disfigurement which has resulted from conditions like cerebral palsy, arthritis, polio, spina bifida or diabetes, are covered.
Understanding what items are covered (and what are not) can help both patients and providers stay informed about the cost involved and who would finally be required to pay. Most items will require to be prior authorized to ensure that their cost is reimbursed. It is also important to bear in mind that insurance companies will insist on paying only for the least costly item to meet the patient’s medical needs.