05/15/2023    Paul Kesselman DPM

CA Podiatrist Discusses How to Get Insurance to Cover AFOs

Kudos to Dr. Ritchie on his presentation on how to
get insurance to cover AFOs. It was well presented
and timely. Many past webinars and articles
presented or written by podiatrists, orthotists,
pedorthists, and others have discussed this
subject. However, there remains resistance to
providing AFOs, particularly when the provider
identifies a patient has already received another
AFO within the past five years (AKA Same or
Similar). While I understand the resistance and
difficulties and time costs associated with the
appeals process, this should be straight forward
and can be streamlined.

It is important to remember that you as the
prescriber and supplier, unlike with therapeutic
shoes, have 100% complete control over all facets
of the documentation. This includes everything from
patient intake, eligibility confirmation, use of
portals and your chart notes. If you fail to do
what is necessary on the insurance intake side and
your documentation is poor or inconsistent with
Medicare or third-party coverage, your claims will
be denied.

In the case of the Same or Similar, there have been
innumerable articles by CMS and all four DME MAC on
how to successfully navigate this issue and with
little time costs, successfully appeal your claims.
It all starts and ends with your documentation
which again is totally within your control!

As the DME Workgroup chair for APMA, we are
currently working on a series of Podcasts on how to
navigate the Same or Similar process and provide
examples of successful documentation. Hopefully
this will assist those of you who are hesitant to
provide AFOs as part of the progression of care and
thus improve patient outcomes.

Lastly, there is pending legislation which hopes to
separate orthotics from DME. This long-term
solution has the potential to rid us of this
ridiculous five-year rule.

Paul Kesselman, DPM, Oceanside, NY

There are no more messages in this thread.