Managing Your Practice's Orthotics Program

Created in partnership with the American Podiatric Medical Association.

Welcome back to Podiatry Today podcasts, where we bring you the latest in foot and ankle medicine and surgery from leaders in the field. In this episode, we are partnering with the American Podiatric Medical Association to bring you our guest, Dr. Jordan Stewart, who's speaking with us today about appropriate management of an orthotics program.

Jordan Stewart, DPM is a fellowship-trained podiatrist in Maryland and founder of the Timonium Foot and Ankle Center. He's board-certified by the American Board of Foot and Ankle Surgery, and served for eight years on the executive board of the Maryland Podiatric Medical Association, including two years as president. As a member of the American Podiatric Medical Association, he is active on the durable medical equipment work group, which addresses DME issues at a national level.

So a common theme that I've noticed, and I know many of us have when it comes to successful billing, coding, and documentation in medicine overall, seems to be preparation. So in that spirit, what policies, documents, or processes do you recommend DPMs have in place when it comes to having a successful orthotics program?

Jordan Stewart, DPM:

So I think just in general, preparation before the visit for any of the services that are provided in the practice are important. Nowadays, we're living in an environment where patients have high deductible insurance plans. Of course, we should give the patients the opportunity to understand and know their benefits. Although it's not our prime responsibility to know everybody's benefits, the reality is the patients don't know their benefits.

And orthotics would be included in this. I think that any good preparation before a patient visit would be for an office staff to verify benefits for the services that are provided by the practice. For example, in our practice, we always verify five services, which include office visits, x-rays, whether it's ultrasound or x-rays, durable medical equipment in general, orthotics as a separate entity, and then surgical procedures, whether it's in the office or outpatient setting.

On top of that, preparation would also include making sure that you're familiarizing yourself with the rules and regulations for each insurance company. Now, of course, that's always a challenge, but it's important that you understand and know the LCDs, what is covered and what... Just because you think an orthotic might be the appropriate treatment, doesn't mean that it's not the appropriate treatment. The insurance company might not feel that it's an appropriate covered service. So making sure that if you are wanting to bill certain items for whatever you're doing, orthotics, of course, included, you want to make sure you have an understanding of the policy.

I always recommend for policies that of course, it's impossible to memorize every detail, and it's easy to confuse one policy versus the other. Having a copy or a folder with the different insurance companies and their carved out policies. Most of the insurance companies do have policies for durable medical equipment for orthotics. They'll very specifically indicate what a covered service is, what a covered service isn't, and also just making sure you're telling your patient this is what the policy states. Sometimes, the claim may process a little differently than what we anticipate, but the bottom line is if you are educated on the policies, it makes it a lot easier for you to explain it to the patients and to give the patients a realistic understanding of what may or may not happen once the claim processes.

Jennifer Spector, DPM:

What about patient-facing documents, an orthotic agreement or an advanced beneficiary notice?

Jordan Stewart, DPM:

Let's go to the immense beneficiary notice first. I mean, certainly Medicare does not cover custom foot orthotics. There are a handful of secondaries to Medicare that will cover orthotics. In my experience, I'm in the state of Maryland. We live near DC, so a lot of the federal Blue Cross Blue Shield plans will cover them under their specific policies. But generally speaking, Medicare, Medicare Advantage plans, TRICARE, they do not cover orthotics. Some of the private carriers do not cover orthotics.

And I think that whether it's a Medicare plan or whether it's a private plan, you should have an advanced beneficiary notice that should very clearly state that this is not a covered service. And for example, even if it's a covered service for their policy but not for their diagnosis, I'll frequently get people to come in and they just have metatarsal joint pain. And metatarsalgia is not generally a covered service. So their plan may cover orthotics or plantar fasciitis, but not for metatarsalgia, and you have to very clearly indicate on that advanced beneficiary notice this is not a covered service by your insurance, or this is not a covered diagnosis for your insurance. Clearly state the cost. And I would highly recommend that you're collecting for the money at the date of service. And if you don't collect for the non-covered item, just understand you're going to be chasing the patient down regardless. Just one of those things where know what you're getting yourself into.

Now, I've been doing this, now this is my 17th year of practice. When I first started, I hated asking people for money. I hated talking about money. I still don't like talking about money with patients. But the bottom line is you don't want to be in a situation where you're paying for something for the patient when it's a reimbursable item. As far as having an agreement, I think that you should clearly have an agreement. We have an agreement that clearly states we have verified your insurance coverage as a courtesy. We outline what the insurance has stated. For example, your insurance has indicated that you have a 75% coverage. You're responsible for 25%. If there's a deductible, we will state that you still have $900 on your deductible. All of the deductible goes towards the orthotics. You'll be responsible for paying for this.

It also says in there that we verify benefits as a courtesy to you. Although the benefits are frequently accurate, there are certain times where they are inaccurate. In the event that they are not... Whether they verify differently than we're discussing, just know that you are ultimately financially liable for the device at our standard fee of X and whatever your standard fee is. You have to have that document.

I also think it's important from a documentation standpoint that you have a receipt of the orthotics in your medical record as well. Certainly there are times where patients pay for orthotics. We see it, believe it or not, you have patients pay several hundred dollars for stuff and they just never come back. For what reason that is, I have no idea. If I pay for something, I'm certainly going to try to get what I paid for. But you want to have a record of the patient getting the orthotic, receiving the orthotic, making sure that that same document indicates that you've gone through the break-in instructions. Of course, you or your staff should be going through that. And it's just a good way of recordkeeping and making sure.

We actually, in our practice, for any custom braces or custom devices, we have an internal spreadsheet where we write down the day that they're going out. We have a check-in process when they're coming in. Are there errors? Yes. But it's very infrequent, especially with the recordkeeping that we've implemented.

Jennifer Spector, DPM:

So it seems that clear communication and patient education is very helpful when it comes to navigating this process. When you're talking to patients about their orthotics, are there any specific elements to that discussion that you recommend that clinicians include?

Jordan Stewart, DPM:

I think that it's important for patients to understand that orthotics are just part of the treatment plan. I think that in my experience, I always tell patients you have to think of orthotics as a spectrum of treatment. I would rarely recommend an orthotic as the sole treatment because in my experience, orthotics are really the backend of treatment. And what I mean by that is, for example, if someone comes in with a PT tendonitis or a plantar fasciitis, if frequently you put them in an orthotic for plantar fasciitis and they actually will complain that their foot is hurting worse because when you put a semi-rigid surface against a painful area, you're likely to just exacerbate pain.

So I think that the realistic expectation is that statistically, and I can say this from doing this for a long time, the majority of patients do well with orthotics. The majority of patients tolerate orthotics. But there's always going to be outliers, and they have to understand, just like anything in medicine, there are no guarantees. I also emphasize that orthotics are a custom device, and because of that, they can be modified as needed. So I always educate the patient and say, "On the day we dispense them, break them inappropriately, follow the break-in instructions, look out for any irritation, sores, areas of blistering. If you have any of that, please notify the office. If there's any problems with your device, bring it back. We'll try to make modifications in the office. If we're unable to modify the orthotics, we will send them back to the lab for modification."

I think that it's important also that you have a good relationship with your orthotic lab because you're always going to get those one or two patients that just continue to have issues and it's not always... Sometimes it's just the orthotic is not helping them, and it's not their fault. It's just a tricky case.

So communicating a realistic expectation on all pathways with the orthotics from start to finish is very important because I think that patients... There's all these commercials now for these retail stores that are claiming that you get better by coming in. That's just unrealistic. And patients come in all the time and say, "I just want an orthotic." And I tell them very bluntly, "An orthotic is not your primary treatment. It's part of your treatment." So we'll typically treat the plantar fasciitis, PT tendonitis immediately.

We'll recommend orthotics a lot of times for those conditions, assuming they're in the guidelines of their policies or if they're paying for it out of their pocket. And then by the time they come back, they're generally ready to transition into that device and start the recovery or continue the recovery, rather. Excuse me.

Jennifer Spector, DPM:

So my experience was similar to yours that you mentioned before, and I think many docs would agree that we don't enjoy talking about money with people. However, we do have revenue that needs to be collected for orthotics many times. So in your experience, is there an ideal time where offices can collect the anticipated balance, whether that be a deductible, a co-insurance, et cetera, owed from that patient?

Jordan Stewart, DPM:

Yeah. I mean, I have always, from day one of my practice, gone under the guidelines of collect everything that you provide at the date of the service. I think that a good rule of thumb is that part of this topic goes back to what we were talking to earlier where you have to be armed with information. In other words, if you have the information regarding their insurance policy... And I always make it an effort to tell them, "Listen. This is what we've looked at, but sometimes the benefits are incorrect." And as a matter of fact, there's been an episode here where we've found a repeating error on one of the insurance websites where orthotics are being quoted as covered at 100%, and the max benefit is 50%. But it doesn't state that on the website, and it states that the patients have 100% coverage, and we've learned our lesson.

But the bottom line is we print out some of the insurance companies will have cost estimators. So you can go on the cost estimator, put the code that you're billing, put the diagnosis, and it'll say whether it's covered or not. Frequently, the patients will come in and say, "Well, I called the insurance company and they said they're covered." And I just put the kibosh on that immediately and say, "Listen. The insurance companies can tell you one thing and tell me another thing."

But getting back to your question specifically about arming yourself with the information of what the anticipated costs are, and then collecting for those services at the data service, I don't find it unreasonable to collect half on an orthotic. In all fairness to the patient, they're not picking that device up the day that you're casting for them or scanning them. So it's not unreasonable for them to collect half. And generally speaking, you're going to be covering your cost by collecting half.

With that being said, I don't think it's ever wrong to just get the entire amount. I don't think you're ever wrong to do that. So it's one of those things where I will not send the orthotics to the lab if the patient has not made a payment and we know that there's a patient responsibility, and we tell them that. We say, "Listen. We're happy to make you the orthotics, but we know that there's going to be an expense on your end and you need to pay for this before we make it." Most people are reasonable about that.

Jennifer Spector, DPM:

So you alluded to some challenging situations previously, and so I'm curious how you've handled certain challenging situations such as if a patient is strongly asking you to submit through insurance for devices that you know are not a covered service under the LCD.

Jordan Stewart, DPM:

Right. So with Medicare, I think that's a little easier. With Medicare, you can utilize the GY modifier. If you know something's not covered, you can still submit it, have them sign the ABN. They can opt to have you submit it, but you're putting the modifier on there that indicates that they're not going to have coverage or you know it's a non-covered service.

It's always a little trickier when you're dealing with private insurance because the truth of the matter is that the private insurance carriers don't really recognize the GY modifier. So you really need to stick with your guns and stick with the office policies. For example, if a patient is coming in for an ankle sprain and they want orthotics, generally ankle sprain is not something that's a covered service. And if the policy may cover orthotics but it's not for that diagnosis or we just know that it doesn't cover it, that's where I would say you bring out the guidelines to the patient, show them this is the service, and you have to do what you're comfortable with. But I would say you're always better following the policies than just trying to do something to satisfy the patient.

Truth of the matter is they can submit the claim to the insurance company on their own, or you can try to get the HR department involved for the carrier or for the member who helps to represent the member if it's an employee-sponsored plan.

That's a very tough situation with private carriers. I think that the truth of the matter is we really need some sort of modifier that indicates that we're billing something on behalf of the patient that we know is not a covered service because ultimately, if it ends up paying, you look like you are lying to the patient, although you're not, and then you're in a situation where you're collecting money for services where the policy indicates that it's not covered. And the truth of the matter is what will likely happen is in the future that will correct the claim, and then they're going to come after you for the money, and then you're going to be stuck chasing the patient down. So I think the best rule of thumb is do what you're comfortable with. When it comes to patients that want to do things that are pushing me, I just would rather lose the business than deal with the patient. That's more challenging because ultimately, it's always going to be an issue.

And as far as other dicey situation with orthotics, I am a big stickler for sticking by my guns. And we tell the patients, "Once the orthotics are made, they're made. That's it. You can't cancel them." I think that occasionally we'll get patients that are very, very challenging. And if we can capture a cancellation within the first day or two when it's in the lab and there's no penalty to us, sometimes it's just worth cutting the cord and just letting that patient go because you know that for a couple of hundred dollars that you're going to make, you're really going to be married to a problem, and it's just not worth it.

Jennifer Spector, DPM:

So we've talked about a lot of different vital concepts when it comes to orthotic program success. But to end our conversation today, what one thing in your experience can DPMs do today to improve their overall orthotics process?

Jordan Stewart, DPM:

So if there's one big piece of information that I could share, and I think this would apply to anything in practice, particularly when you're dealing with custom devices, is just be as transparent as possible. Understand that the patient's looking for a service. You had the opportunity to make money. But just make sure it's right. Just be transparent and honest because the more transparent and honest you are with patients, the more they're going to have faith in you, believe you, trust you, and understand that you're guiding them in the right direction.

There are plenty of times where I have patients come into my practice and they want orthotics for shoes that just will not accommodate orthotics, and they're willing to spend the however much we charge price for the orthotics. And I'll tell them that it's just not worth it. You'll get patients coming in frequently that want them for four different pairs of shoes. And yeah, maybe having one extra set is reasonable in certain circumstances, but I think that being realistic for the patients and not just... Being cost-conscious for the patients when you can, and being transparent as to the expectations with orthotics will make your life easier.

If you're very open and honest, don't... Try to minimize those surprise bills, meaning that if you know something's not going to be covered for a patient and you do it, and then expect them to not be mad when you flip them a bill for several hundred dollars that they weren't expecting, you can avoid all of that by discussing things out open in the front.

And I think the other thing is you just have to get comfortable talking about money because right now, in the day and age of medicine that we live in, there's not a lot of things that don't go towards a deductible and there's not a lot of patients that don't have deductibles, but maybe you can try to educate your patients on that. So that's the most important thing that I would say, is just being as transparent as possible.

Jennifer Spector, DPM:

Thank you so much, Dr. Stewart, for sharing your insights with us today. And thank you to the American Podiatric Medical Association for partnering on this podcast episode. Be sure to tune into future and past episodes of Podiatry Today podcasts on podiatrytoday.com, SoundCloud, or your favorite podcast platforms.