Friday, February 23, 2024

Shoe reimbursement-replies part 1

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.

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