Every day we are asked “Is this covered by my INSURANCE?”
It’s a simple question with a complicated answer. Insurance coverage is a contract between the employee and the coverage provider in question, administered through the company you work for.
The amount of information needed to process a claim varies greatly between plans and the information pertaining to the plan is Private and Protected information. That means that we, as service providers, are not privy to the information needed to give you a straight answer.
We DO NOT DIRECT BILL for Insurance Policy Claims and can NOT call them on your behalf, due to the privacy rules. To find out about your coverage we recommend you call your provider company and discuss it with them.
Here are some guide line questions that should help you determine the coverage available to you through your Insurance Provider:
1. OverTheCounter (OTC) vs Custom
Your booklet may say that you have coverage for ‘orthopedic footwear’ but you need to know that some guidelines call for ‘Custom Made via Casted Forms’ only. Other plans may have a list of accepted orthopedic footwear that qualify for coverage. You should ASK FOR A COPY OF THE LIST AND GUIDELINES. Many of the shoes we carry DO qualify as OTC Orthopedic based on the features and design of the model in question, but because of privacy we can not ask those questions for you. Stockings typically are covered only once you reach a specific level of compression (20-30 mmHg and above), and plans typically have a limit on the quantity. Orthotic insoles usually must be made via a cast of your foot, not pre-made adjusted devices.
2. Total Dollar Coverage
This is an important question because coverage has not kept up with the cost of inflation in most cases. Custom Made Footwear from scratch will START at about $1800.00 and can range up to $3000+, depending on the requirements for the device in question. OTC Orthopedic shoes will typically range between $150 – $400. If you only have $250.00 coverage for ‘orthopedic footwear’ you should know which version you are really discussing! Coverage for orthotics has not kept up with the cost of inflation in most cases either. Custom Made Orthotics should take about a week to make & the cost of a true MOULDED device should be between $400 – $500. A few people tell us “I only have $250.00 coverage… can I have it for that price?” The reality is, If your orthotic dispenser changes their prices based on the $$ available to each client there’s a good chance that those are NOT custom moulded devices, rather, customized. It takes time and training to be able to do a Gait Analysis and design your devices properly.
3. Frequency / Reset Date
This is important because if you need Orthopedic Footwear it’s for a reason.We have more than one season and we know that we wear different kinds of footwear depending on weather conditions and activity. The same can be said for orthotics too… you may be a runner but have an office job and need two different types of devices. Stockings are rated for compression value for only about 6 months of continuous wear, then their compression value drops. Some plans cover devices only once per lifetime while others reset annually and cover multiple items per year!
4. Plan Specific Restrictions
Most insurance providers now require a DIAGNOSIS (Dx) written on your prescription(Rx). As mentioned above, some plans have a specific list of accepted footwear (again, ask for a copy of the list or ‘guidelines’). We can not tell you the rules of your plan. Call your provider for information regarding the rules for coverage, just in case there is a specific guideline that must be fulfilled.
About the Prescription (Rx)
In general you should have an Rx from an independent source that has no vested interest in whether or not you purchase a device. This step can help to ensure that you are not being told you need a device just to make a sale.
We also recommend that you ask that a Diagnosis (Dx) be included on your Rx. This means no ‘ foot pain’ or ‘back pain’ or ‘for medical reasons’. (It’s pretty much a given that you are having pain/discomfort; that’s likely WHY you are looking for orthotics. They’re not for cosmetic purposes after all.)
Diagnosis should be in medical terms, not common terms. Here are some common examples:
‘Heel Pain’ is the symptom,not a diagnosis.
WHY do you have heel pain? Is it because of ‘planter fasciitis’, heel pain syndrome, pinched nerve or is it a broken heel bone?
‘Flat Feet’ is the symptom.
Many people have flat feet and don’t have any pain or problems… the question is WHY are those feet flat hurting you? Did you crush both feet as a child? Do you have STJ Over-Pronation? Do you have Post-Tib. Tendenosis? It’s important to know WHY you are in pain!
Your diagnosis will help to determine what kind of treatment you will require! Have your Doctor call us if you have questions.