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Orthotics and Your Insurance

While most insurance companies allow clinics to direct bill for services such as chiropractic, physiotherapy, and massage therapy, the majority of companies will not allow direct-billing for products such as orthotics. This, and the many other details surrounding orthotic insurance claims can be confusing to patients, and so I thought I would take the time to share my experience. If you are considering purchasing orthotics, read on!

COST

This can be a touchy subject for some, as custom-made Orthotics can be quite expensive, costing typically between $450.00 and $650.00. This can vary clinic to clinic, and patient to patient, as it is dependent on many factors, such as how much a particular clinic may charge for your clinician's time, as well as the cost and complexity of the orthotic.  At MiltonBackDoc this fee includes the initial assessment, the custom-made orthotic, and the pick-up visit. During the initial visit we normally require a $100.00 deposit, which is applied to the final cost, while the remaining balance can be paid upon pick-up. If you come in for an orthotic assessment, and decide either not to pursue them after all, or the practitioner deems that orthotics would not be appropriate, you should only be charged for the  chiropractic assessment fee, rather than the full orthotic cost.

PAYMENT

Most insurance companies require a paid-in-full invoice to process your claim. This means that patients must pay for the orthotics, and submit the receipt showing the full payment to their insurance company before the claim is accepted and reimbursed. At MiltonBackDoc, we are happy to assist you with the paperwork to make this process as quick and efficient as possible. While there are a few insurance companies, such as Greenshield and Great West Life, that will often (but not always!) pay us directly for orthotics, most will not.

PRESCRIPTON

Orthotic submissions to insurers always require a prescription. While I have come across a few insurance plans that will allow a Chiropractor to prescribe orthotics, the majority of benefit plans require that the prescription be written by a Medical Doctor, Chiropodist, or Pedorthist. If you intend to make an insurance claim for orthotics, it is important to obtain this prescription before they are sent to be manufactured. When obtaining this prescription, ensure that your physician includes a diagnosis! Physicians will often write down symptoms such as “foot pain,” “knee pain,” or “low back pain”. While these are the types of things that orthotics are effective for, they are still symptoms and not a diagnosis, and as such are not usually accepted by insurance companies.

TIMELINES

Custom-made orthotics take time, as they are not off-the-shelf items.  The entire process, from the time you attend the clinic for the initial assessment to the time the orthotics arrive back in the office, can take between 3 and 6 weeks. At MiltonBackDoc, we are often able to rush orders, shortening the manufacturing timeframe significantly, however this incurs an additional charge of $25.00. Certain times of the year tend to be busier for orthotics manufacturers than others, such as in December, and this can also influence the timeframe. Often during busy seasons, rush-orders are not accepted. These things are important to consider if you have a particular deadline, for example if your benefits are changing or renewing (such as starting a new job, or starting a new benefit year) as the majority of insurance companies consider a claim based on the date that the orthotics were picked up.

EVERY PLAN IS DIFFERENT

While, at MiltonBackDoc, we will try to assist you to make the orthotic claim process as easy and efficient as possible, every insurance company and each individual plan have different requirements. As coverage percentage and maximums vary considerably from plan to plan, it is always recommended that you contact your insurance company prior to attending the clinic so that there are no unexpected costs or surprises. If you are having difficulty with your insurer, or you feel you require assistance, feel free to contact the office. Depending on your insurance company, we may be able to call on your behalf before your appointment.  Some insurance companies, however, require verbal consent from the patient in the office before they will disclose insurance information to the clinic. Lastly, some insurance companies will not disclose dollar values or the percentage coverage information over the phone, and instead require an estimate to determine if a claim will be accepted. In the case that an estimate is required, it could add up to 3 or 4 weeks to the process.

QUESTIONS TO ASK WHEN YOU CALL YOUR INSURANCE COMPANY

  • Do I have custom-made orthotic coverage on my plan?
  • How many pairs am I covered for each cycle?
  • What percentage is covered (100% or partial)?
  • What is the maximum payable (dollar amount) per pair? Per year?
  • Is orthotic coverage based on a calendar year, or other benefit year? (Or 12 rolling months, 24 rolling months, etc)?
  • Do I require a prescription?
    • If so, can a chiropractor write the prescription?
    • If not, who can write the prescription (eg. medical doctor)?
  • Can a chiropractor dispense the orthotics?
  • Is assignment of benefits allowed? (ie. will they pay the clinic directly?)
  • Is there a deductible?
  • If you are interested in sandal orthotics, make sure to ask if custom-made sandal orthotics are covered, as some plans which cover orthotics will specifically not cover sandal orthotics

If you feel that your situation is unique, or you have further questions that I have not addressed above, please feel free to contact the office! We are here to help!

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