I have just been asked my opinion on 2 patient/orthotist problems. The
patient was given an RX for bilateral
G2’s with AFO attachments. The orthotist (who is the HMO designated O&P in
the area) received approval from the HMO insurance provider at a particular
price. Then the orthotist called the patient and told her that the HMO
would not pay for the cast molds of the legs so she would have to pay or he
would not make he brace.
The HMO feels the casting process is part of the L code pricing. The
questions asked of me is
1. Is this a customary practice to charge for casting after the
authorization is given?
2. Is this against the rules of ABC?
3. Should this Orthotist be reported to the HMO(probably done already), the
ABC, & the Florida O&P
Board.
The second problem is an orthotist who received an Rx to do a certain custom
OA brace. He then called the Doctors office and asked to switch the brace
to another brand. The Doctors secy thought this would not be a problem. The
secy now says she was blind sided by the orthotist who made it sound like
this was a normal procedure. The orthotist switched the brace to a cheaper,
off the shelf, ACL brace. He didn’t even use an OA brace. What should we
do in this case?
Charles Barocas, C.O.,
