Does Insurance Cover Orthotics? Learn More from a Podiatrist, Dr. Alan Bass

Alan L. Bass, DPM, CPC

Central Jersey Foot and Ankle Care, PC

The Importance of Incorporating Top Quality Prefabricated Orthotics into Your Practice

I thought I would take this blog to both educate and provide some “food for thought” when it comes to utilizing both prefabricated and custom orthotics in relation to insurance.

I recently had a conversation with another podiatrist about what company I utilize for custom orthotics. That talk lead to a discussion about the types of patients that a practice sees and how the use of orthotics, both custom and prefabricated fit into the usual podiatric practice.

The patient population of most practices can be divided into 4 major groups: Medicare (and all the advantage plans), Medicaid, commercial carriers, and non-insured/non-covered or cash-based patients. While the treatment of your patients should never be dependent on the insurance, or the lack thereof, that must be considered. As any healthcare provider, we have a duty to provide the best care to our patients. Nowadays, the insurance a patient has can affect the outcome.  

In the almost 30 years that I have been in practice, the coverage provided by commercial carriers has changed often. In general, when a patient has asked me if orthotics are covered by their insurance, I take this opportunity to educate the patient on commercial insurance. First, I let patients know that orthotics are considered durable medical equipment (DME). Patients are usually unaware that the medical coverage that they are offered is determined by the level of coverage that is chosen by their employer. Since most employers supplement the out-of-pocket monthly costs for their employees, employers will determine how much they want to contribute. This may or may not include coverage for all types of DME, including custom orthotics. There may also be a different copay, coinsurance, or deductible for DME. It is incumbent for all patients to know what their financial responsibility is. As a provider, while you want to provide the best care for your patient, if the patient must incur a large out-of-pocket expense for orthotics, they may choose to seek an alternative. Another factor to consider is that coverage by commercial carriers for orthotics is also dependent on the diagnosis that the patient presents with.

For Medicaid, coverage is normally allowed but may have coverage limitations by both the carrier and patients diagnosis. It is incumbent on the provider to know the rules of the specific Medicaid carrier in their state. It has been my experience that Medicaid will most likely cover custom orthotics.

Let’s discuss the non-covered, non-insured patient; the cash-based patient. When it comes to this patient, I will urge you to consider the marketplace and what the investment by your patient needs to be. Remember, if there is a benefit to the patient it’s an investment in their foot health, and not a cost to the patient, which indicates no benefit.

This leads me to the educational portion of this discussion, Medicare. When it comes to Medicare, there is one hard and fast rule that all providers must follow. Medicare only covers the use of custom orthotics when the orthotic is placed into a shoe that is attached to a leg brace. That’s it. There are no exceptions to this rule. It is the same whether it is a traditional Medicare plan, or an advantage plan run by a commercial carrier such as United Healthcare. It is also incumbent on us to educate our patients on this. Patients who need a pair of custom orthotics for a biomechanical deformity, and do not have a shoe attached to a leg brace, who have Medicare and a secondary insurance may ask a provider to submit the claim on their behalf. First, remember to have the patient sign an ABN. The use of the GY modifier on the claim, indicating that the service, or in this case, the orthotics are statutorily excluded and not covered by Medicare, must be appended to the claim. As a provider you may request payment upfront since the orthotics are not covered. If they have a secondary insurance that covers the claim after submission of the claim to Medicare with the GY modifier, you may be paid by the secondary insurer. You then have an obligation to return the money you have collected before submission of the claim. Patients who have an advantage plan may ask us to submit the claim and the same rules apply here as with traditional Medicare.

When it comes to orthotics and Medicare, the patient may call Medicare, or their advantage plan, and ask if the code you are going to use for billing is covered. More times than not, a patient is told that the code for orthotics is covered, but the representative does not inform the patient about the use of the shoe attached to a leg brace.

I believe that the story below will show you how I have incorporated prefabricated orthotics into my practice from both a clinical and a revenue standpoint. For the commercial based patient, who may have coverage for custom orthotics, are custom orthotics always needed? Are they always first line of treatment? For example, I had a patient in this past week, who may or may not have had coverage for orthotics. That is unimportant. Every patient is an individual and needs to be treated as such. This patient came in with a 4-week history of right heel pain. While examining this patient and showing him that the over-the-counter arch supports that he bought in the pharmacy were not providing him the support he needed, he said “that’s $15 down the drain”. Instead of saying “yes, you are correct”, I took the opportunity to educate this patient on why investing a little more money, will allow him to utilize high-quality, prefabricated orthotics that will most likely help his plantar fascial pain. While I write this blog, I do not know how this patient will be when he returns for follow-up, but historically, these patients have done very well with the use of the PowerStep ProTech orthotics that I dispense from my practice. Patients do appreciate that they can walk out of my practice with something that will help them immediately.

When it comes to the use of prefabricated orthotics in my practice, I let patients understand that this may be all they need. I also tell them that the orthotics may only get them 75% to where they need to be and may need to invest in the use of a custom orthotic. If that patient does have insurance coverage for orthotics, you always can dispense custom orthotics, an additional revenue source. 

Dispensing prefabricated orthotics from your practice for the Medicare population will also allow you to provide the patient with the best alternative to custom orthotics, should they not qualify for coverage under Medicare guidelines.

The investment in prefabricated orthotics in the Medicaid population should also be considered in certain circumstances. While this patient will most likely have coverage for a pair of custom orthotics, multiple pairs may not be covered. The investment by the patient in the PowerStep ProTech orthotic as a second pair may allow them to get the best orthotic after the use of custom.

The non-covered, non-insured cash patient will also benefit from the use of the ProTech orthotics if they are not the right candidate for, unable to, or unwilling to invest in the use of custom orthotics

That brings me back to the conversation with my fellow podiatrist. I asked her how she uses prefabricated orthotics in her practice. I asked her what she does in her practice about utilizing them in each of the scenarios we discussed above. Her response was not surprising, as I have heard it way too often. She told me “I give them the name of an orthotic to buy off Amazon”. If you refer to my previous blogs, you will see the importance of not doing that and having prefabricated orthotics, especially the PowerStep ProTech orthotics in your practice for immediate dispensing to your patients.