Shoe reimbursement-replies part 1
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Title:
Shoe reimbursement-replies part 1
Text:
Thanks to those who responded!!
THE ORIGINAL POST:
Question to orthotists-
A) Considering the cost vs reimbursement for shoes and related add-ons, do
you provide shoes at break even (or at a loss) and write it off as a cost of
doing business, or do you avoid getting involved in billing for shoes?
B) If you do procure shoes and bill for them, what have you found to be the
most cost effective shoes for diabetic patients?
C) Are you part of the Medicare diabetic shoe program? Why or why not?
I'll post replies.
Randy McFarland, CPO
Fullerton, CA
THE REPLIES: separated by a blank line
In our practice, shoes and related items are the black hole. They make up
the charity in our practice. We discuss it at every meeting and never
resolve the issues surrounding the cost vs reimbursement. I will be very
interested to see the responses.
It is definitely not a money maker! Yes, we have calculated that we lose
with almost each case. It IS a cost of doing business and is offered as a
service to our clients ONLY because NO ONE else in our town or surrounding
area offers the service. Sad to say, but some of these patients will
eventually be amputees and return to us. There is at least some
profit in prosthetics. With diabetic shoes, when you consider the time
involved in evaluation, fabrication and office visits, you have definitely
lost. The reimbursement is pitiful.
We do not look at cost effectiveness alone to determine the shoes for
diabetics. We use mostly PW Minors. There are others available (Urban
Walkers, Apex, etc) that are cheaper, but offer little selection and do not
last as long. We have discussed the option of limiting the client's choice
to 2 or 3 varieties to save money, but what do you do with those who have
already been successfully fit with PW Minors? Change them? No way. If the
patient is forced to choose a shoe that does not satisfy their cosmetic
concerns, they will not wear the shoes and what have you, as an Orthotist,
accomplished? Nothing with shoes that sit on a closet shelf.
We are part of the Mcare program as noted in PP#1. No one else offers
the
service. Because it's a money loser!
Our policy is to bill for the shoes. You are correct that the reinbursement
is terrible. We do not make hardly anything off the shoes themselves. We do
make a little (and I mean just a little) off the diabetic inserts that we put
in the shoes. We bill for diabetic shoes, up to three pairs of inserts a
year, and diabetic modifications (such as a wedge-A5504) that there are codes
for. If we do a modification on a pair of diabetic shoes that does not have
a code (like an elevation or met bar) we offer to provide it to the patient
at a reasonable price. It has been known for orthotists to provide two pairs
of diabetic inserts/year to their patients and do shoe modifications and in
return bill for all three pairs of inserts for reinbursment. I do not
recommend trying to make a living off of diabetic shoes, inserts, or their
modifications, but if, by providing the shoes and inserts, we are preventing
further problems and still breaking even (or even making marginal profit), I
say so be it. We like to use P.W. Minor shoes or Apex Ambulators.
A - We lose. We send patients to a local shoe store which bills us their
normal price. We lose on every pair of shoes we provide. Fortunately we
don't do a lot.
C - Yes.
As far as shoe reimbursement for the diabetic we are selective because we do
not participate as a medicare contracted provider. When patients are able to
pay for their shoes we prefer to be paid and submit the medicare forms in
stating we did not accept assignment so that the check goes back to partially
reimburse the patient.
In the orthoses situation when the shoes are attached to the orthosis we try
and usually succeed in being reimbursed for the shoes. In the case of the
patient who cannot pay we usually work something out or adjust accordingly.
As far as types of diabetic shoes we've successfully used APEX< PW MINOR and
Comfort Rite. The other brands like Drew and Alden are just too pricey for
the diabetic. Also we take in to consideration the usual need for plastazote
liners/inserts that are also billable and reimbursed by medicare.
a) We don't accept assignment on diabetic or any other shoes. We try to avoid
them due to low reimbursement and hassles. We are not able to provide them at
all to Medicare/MediCal pateints due to reimbursment issues.
b)APEX ambulators seem to work well and can meet reimbursmetn requirements
when necessary.
c) we avoid the therapeutic shoe program where possible. At times we ahve to
provide to solve other problems ie, partial foot prosthesis, AFO
requirements, etc.
A) Yes, It is a break-even proposition. When you consider the cost of
having stock, Fast shipping for sizes or styles not in stock, practitioners
time and cost of billing and collecting -- a practice would be lucky to break
even.
B) I Have found the Apex Ambulator works well, esp. their multidensity
inserts.
C) As I understand it, if we accept assignment for O&P, then we are
obligated to accept for pedorthics. Please somebody, anybody correct me if
I'm wrong.
The real DILEMMA I face is what if this diabetic, Medicare patient
requires a custom molded insole? There is only one A code: multidensity
insert (it doesn't say molded to patient model) and the allowable is $28.50.
Can I bill an L code with the appropriate description (Medicare will deny,
then it will be the patient's responsibility)?
Shoes for our company has always been an evil but necessary service. Most
of our referral sources have patients in need of orthopedic or depth inlay
therapeutic shoes. Most O&P providers in our area shy away from providing
shoes. We used to actively pursue referral sources to provide shoes hoping
that we would be called on to provide P&O services when necessary.
This worked to some extent, but as you know the reimbursement rate is
probably break even at best for the majority of shoes delivered to clients
on Medicaid or Medicare (after taking into account the actual costs of doing
business.) We have ceased providing shoes to referrals who are not in some
way connected to our sources where we provide P&O services; unless of course
they are self pay and willing to pay our scheduled fee for the shoes and
personalized service for custom fitting.
We only accept Medicaid and Medicare coverages as appropriate to provide
shoes which are indicated for the myriad foot conditions and deformities;
the procedures for reimbursement from these insurances are streamlined (at
least in our practice). The administrative costs in trying to get
reimbursed for shoes with private insurance companies are prohibitive, so we
don't accept private insurance for these services.
THE ORIGINAL POST:
Question to orthotists-
A) Considering the cost vs reimbursement for shoes and related add-ons, do
you provide shoes at break even (or at a loss) and write it off as a cost of
doing business, or do you avoid getting involved in billing for shoes?
B) If you do procure shoes and bill for them, what have you found to be the
most cost effective shoes for diabetic patients?
C) Are you part of the Medicare diabetic shoe program? Why or why not?
I'll post replies.
Randy McFarland, CPO
Fullerton, CA
THE REPLIES: separated by a blank line
In our practice, shoes and related items are the black hole. They make up
the charity in our practice. We discuss it at every meeting and never
resolve the issues surrounding the cost vs reimbursement. I will be very
interested to see the responses.
It is definitely not a money maker! Yes, we have calculated that we lose
with almost each case. It IS a cost of doing business and is offered as a
service to our clients ONLY because NO ONE else in our town or surrounding
area offers the service. Sad to say, but some of these patients will
eventually be amputees and return to us. There is at least some
profit in prosthetics. With diabetic shoes, when you consider the time
involved in evaluation, fabrication and office visits, you have definitely
lost. The reimbursement is pitiful.
We do not look at cost effectiveness alone to determine the shoes for
diabetics. We use mostly PW Minors. There are others available (Urban
Walkers, Apex, etc) that are cheaper, but offer little selection and do not
last as long. We have discussed the option of limiting the client's choice
to 2 or 3 varieties to save money, but what do you do with those who have
already been successfully fit with PW Minors? Change them? No way. If the
patient is forced to choose a shoe that does not satisfy their cosmetic
concerns, they will not wear the shoes and what have you, as an Orthotist,
accomplished? Nothing with shoes that sit on a closet shelf.
We are part of the Mcare program as noted in PP#1. No one else offers
the
service. Because it's a money loser!
Our policy is to bill for the shoes. You are correct that the reinbursement
is terrible. We do not make hardly anything off the shoes themselves. We do
make a little (and I mean just a little) off the diabetic inserts that we put
in the shoes. We bill for diabetic shoes, up to three pairs of inserts a
year, and diabetic modifications (such as a wedge-A5504) that there are codes
for. If we do a modification on a pair of diabetic shoes that does not have
a code (like an elevation or met bar) we offer to provide it to the patient
at a reasonable price. It has been known for orthotists to provide two pairs
of diabetic inserts/year to their patients and do shoe modifications and in
return bill for all three pairs of inserts for reinbursment. I do not
recommend trying to make a living off of diabetic shoes, inserts, or their
modifications, but if, by providing the shoes and inserts, we are preventing
further problems and still breaking even (or even making marginal profit), I
say so be it. We like to use P.W. Minor shoes or Apex Ambulators.
A - We lose. We send patients to a local shoe store which bills us their
normal price. We lose on every pair of shoes we provide. Fortunately we
don't do a lot.
C - Yes.
As far as shoe reimbursement for the diabetic we are selective because we do
not participate as a medicare contracted provider. When patients are able to
pay for their shoes we prefer to be paid and submit the medicare forms in
stating we did not accept assignment so that the check goes back to partially
reimburse the patient.
In the orthoses situation when the shoes are attached to the orthosis we try
and usually succeed in being reimbursed for the shoes. In the case of the
patient who cannot pay we usually work something out or adjust accordingly.
As far as types of diabetic shoes we've successfully used APEX< PW MINOR and
Comfort Rite. The other brands like Drew and Alden are just too pricey for
the diabetic. Also we take in to consideration the usual need for plastazote
liners/inserts that are also billable and reimbursed by medicare.
a) We don't accept assignment on diabetic or any other shoes. We try to avoid
them due to low reimbursement and hassles. We are not able to provide them at
all to Medicare/MediCal pateints due to reimbursment issues.
b)APEX ambulators seem to work well and can meet reimbursmetn requirements
when necessary.
c) we avoid the therapeutic shoe program where possible. At times we ahve to
provide to solve other problems ie, partial foot prosthesis, AFO
requirements, etc.
A) Yes, It is a break-even proposition. When you consider the cost of
having stock, Fast shipping for sizes or styles not in stock, practitioners
time and cost of billing and collecting -- a practice would be lucky to break
even.
B) I Have found the Apex Ambulator works well, esp. their multidensity
inserts.
C) As I understand it, if we accept assignment for O&P, then we are
obligated to accept for pedorthics. Please somebody, anybody correct me if
I'm wrong.
The real DILEMMA I face is what if this diabetic, Medicare patient
requires a custom molded insole? There is only one A code: multidensity
insert (it doesn't say molded to patient model) and the allowable is $28.50.
Can I bill an L code with the appropriate description (Medicare will deny,
then it will be the patient's responsibility)?
Shoes for our company has always been an evil but necessary service. Most
of our referral sources have patients in need of orthopedic or depth inlay
therapeutic shoes. Most O&P providers in our area shy away from providing
shoes. We used to actively pursue referral sources to provide shoes hoping
that we would be called on to provide P&O services when necessary.
This worked to some extent, but as you know the reimbursement rate is
probably break even at best for the majority of shoes delivered to clients
on Medicaid or Medicare (after taking into account the actual costs of doing
business.) We have ceased providing shoes to referrals who are not in some
way connected to our sources where we provide P&O services; unless of course
they are self pay and willing to pay our scheduled fee for the shoes and
personalized service for custom fitting.
We only accept Medicaid and Medicare coverages as appropriate to provide
shoes which are indicated for the myriad foot conditions and deformities;
the procedures for reimbursement from these insurances are streamlined (at
least in our practice). The administrative costs in trying to get
reimbursed for shoes with private insurance companies are prohibitive, so we
don't accept private insurance for these services.
Citation
“Shoe reimbursement-replies part 1,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 14, 2024, https://library.drfop.org/items/show/215034.
