Hello list,
Our clinic is located in Washington State and we have recently run into a situation with Blue Cross / Blue Shield of Illinois. The Boeing Company, which moved it’s corporate headquarters from Seattle to Chicago a few years ago, has changed it’s employee insurance to this Illinois based insurer. Boeing has historically allowed employees to have foot orthotics, usually limited to one pair per year. With the new insurer, they can still get foot orthotics, again limited to one pair per year. However, when they were setting coverage policies, BC/BS of Illinois has confused “foot orthotics” with “orthoses”, and any orthosis that includes the foot is now being denied if any other device that includes the foot has been provided within the previous 12 months.
I had a patient in the office today with a gastroc muscle tear. The injury occurred a few months ago and she had surgery and was placed in a walker boot and it was a covered benefit. Today, the physician wanted an AFO for long term use and coverage was denied, BC/BS Illinios stating that an orthotic had been provided a few months ago. I tried to explain the difference but was not successful. I inquired about other devices such as a TLSO body jacket, knee braces, hip abduction braces, etc, and there was no limitation to one per year. The fellow in the authorization department did not understand the difference between an orthotic device and a foot orthotic and said that BC/BS follows the AMA definition of an orthotic device and that there were no exceptions. He said that if it included the foot in any way, it was an orthotic and it was under the 12 month limitation. When I asked for a supervisor, I was told that there was no one else to talk
to about this issue because the board of directors of BC/BS made the policy.
Has anyone else run into this issue with this or any other insurance carrier? Any suggestions?
Can AOPA look into this?
Thanks,
Karl Entenmann, CPO
Preferred O & P
Federal Way, WA
