Insurance & Billing Guide
Commonly Asked Questions
Q: Do I need to make an appointment?
A: We strongly suggest that you make an appointment, as walk-in patients can sometimes have a longer wait. In addition, by making an appointment, you can make sure that we offer what you need.
Q: What do I need to bring with me to my appointment?
A: If you are a new patient, we will need your insurance cards and a physician’s prescription. Please arrive at least 15 minutes early to fill out the required paperwork. If you are a returning patient, we will need a prescription for new services and updated insurance information (if anything has changed). If you are coming in for an adjustment, we will also need the item that we will be working on.
In summary, please make sure you bring the following information:
- RX or prescription from your referring physician
- All your insurance cards and information
- Personal information: date of birth and Social Security Number
- Spouse’s information: date of birth and Social Security Number. This is especially important if your spouse is the primary insurance card holder.
- If the patient is a child or dependent we will need the primary card holder’s date of birth and Social Security Number. When possible, it is best to have this information for both parents.
Q: Will you accept my insurance?
A: Yes, we accept all insurance carriers. However, depending on your policy, the services you receive here may not be covered. If we are not in-network with your company, they may pay poorly or not at all. To avoid surprises, please ask our staff to verify your benefits before you receive any products that you may not be able to afford.
Q: What will my insurance cover?
A: Our staff will call your insurance company to verify your benefits and eligibility. We will let you know what your insurance company will cover before we begin fabrication.
Q: How much is this going to cost me?
A: That depends on the item that has been prescribed and what your insurance company will cover. After we call your insurance company, we will be able to tell you what your financial responsibility will be.
Q: How much will my first visit cost?
A: Your visits are included in the price of the device you receive; however, any subsequent adjustments to your device (parts, labor, etc.) will be billed to your insurance.
Q: Will my insurance cover this device?
A: That depends on the type of insurance you have. All insurance companies require that the device is medically necessary in order to be covered; however, some insurance companies have non-coverage clauses in their policies stating that they will not cover Durable Medical Equipment, so it depends on the specific coverage in your policy, which we will verify. Some insurance companies require prior authorization, depending on the service. Most insurance companies will state that coverage is not guaranteed and that they will make their determination when the claim is submitted.
Insurance Information
We accept almost all major insurance plans. You, the patient, can check with your insurance company to see if Prosthetic Laboratories is one of their contracted providers (in-network). Generally, insurance companies pay claims differently based on whether the patient uses an in-network provider or an out-of-network provider.
Specific coverage for a certain procedure or device will depend on the patient’s insurance plan and whether it has certain exclusions or exemptions for pre-existing conditions.
It is important to know in advance if your insurance plan requires a pre-authorization or pre-certification before the procedure or device can be delivered. This can sometimes take days or weeks to obtain depending on the insurance company’s system for responding to these requests.
Medicare & Medicaid
You will need to bring the following to your appointment:
- Personal information: date of birth and Social Security Number
- Medicare or Medicaid ID cards
- If you have Iowa Medicaid, we will need your Iowa primary doctor’s name, phone number and address. If you have Iowa Medicaid Medipass, we will need your Medipass number.
Worker’s Compensation
You will need to bring the following to your appointment:
- Personal information: date of birth and Social Security Number
- Any secondary or private insurance information or cards
- Worker’s Compensation carrier information
- Claim number
- Date of injury
- Worker’s Compensation contact person’s name and number
Lair’s Shoes Commonly Asked Insurance Questions
Q: Will these shoes, inserts or modifications be covered by my insurance?
A: With so many different policies available, it is impossible for us to be certain what each insurance plan would cover; however, we can provide you with the billing code to make is easy for you to verify your coverage before proceeding with the services.
Q: Will you send me a bill for the balance after billing my insurance?
A: Yes, we will bill your insurance first. They will then determine if this is a covered service and, if so, how much your co-payment will be. This information will be sent to you in the form of an Explanation of Benefits. We also receive a copy of the Explanation of Benefits. We will then bill you for the amount that your insurance company has determined to be your share of the cost. Your bill will come from our parent company, Prosthetic Laboratories.
Q: What if my insurance policy doesn’t cover the billed item and I cannot afford it? Do you have a payment plan?
A: If your insurance company denies the charges and they become your full responsibility, we will send you a maximum of four monthly statements giving you the opportunity to pay the balance. If, after the four statements, we have not received the balance in full, the account may be sent to collections. We do not have any standard payment plans; however, if you notify us immediately of your need for a payment plan, we will place your request under consideration. All payment plans require manager’s approval.
Q: Do you bill my insurance before I receive my completed inserts?
A: No. We do not bill your insurance company for any item until you have received the item and signed a delivery confirmation form.
Q: What happens if I change my mind after the inserts are made?
A: The inserts are a non-returnable and non-refundable item, whether they are custom made or an off the shelf product.
Q: Does Medicare pay for more than one pair of diabetic shoes per year?
A: No. Medicare covers only one pair of diabetic footwear a year. They will also pay for three pairs of inserts, or six modifications to shoes, or any combination thereof that does not exceed a total of six separate inserts or modifications. The following information details Medicare’s exact requirements:
Information for Diabetics regarding Medicare coverage for Therapeutic Shoes and Inserts
If you are a diabetic with Medicare Part B and you meet certain conditions (see below), Medicare will cover therapeutic shoes if you need them. The types of shoes that are covered each year include one of the following:
1. One pair of depth-inlay shoes and three pairs of inserts or
2. If you cannot wear depth-inlay shoes because of a foot deformity, one pair of custom-molded shoes (including inserts) and two additional pairs of inserts.
Note: In certain cases, Medicare may also cover shoe modifications instead of inserts.
In order for Medicare to pay for your therapeutic shoes, the doctor treating your diabetes must certify that you meet all of the following three conditions:
1. You have diabetes.
2. You have at least one of the following conditions in one or both feet:
• Partial or complete foot amputation
• Past foot ulcers
• Calluses that could lead to foot ulcers
• Nerve damage because of diabetes with signs of problems with calluses
• Poor circulation
• Deformed foot
3. You are being treated under a comprehensive diabetes care plan and need therapeutic shoes and/or inserts because of diabetes.
Medicare also requires the following:
1. A podiatrist or other qualified doctor must prescribe the shoes, and
2. A doctor or other qualified individual, such as a pedorthist, orthotist, or prosthetist, must fit and provide the shoes to the beneficiary.
3. A doctor must sign both the Therapeutic Footwear Statement and the Orthotic Footwear Prescription Card found here: Prescription Cards.
Medicare helps pay for one pair of therapeutic shoes and inserts per calendar year, and the fitting of the shoes or inserts is covered in the Medicare payment for the shoes.
Q: Will my insurance company pay for shoes?
A: There are only two circumstances under which an insurance company will pay for shoes. The first is if you are a diabetic. The second is if your shoes are physically attached to a brace. In both instances, your insurance company will need proper documentation to verify that you are a diabetic or to verify the medical necessity of having your shoe attached to a brace.
Silhouette Shoppe Commonly Asked Insurance Questions
Q: Will you accept my insurance?
A: The Silhouette Shoppe accepts most forms of insurance; check with your individual plan for specific item coverage. Also, many plans have limitations and may require you to pay for a portion or all of the items purchased.
Q: What does insurance cover?
A: With the exception of Medicare, we cannot guarantee coverage by your insurance company. Therefore, we urge you, as our customer, to directly contact your insurance company prior to your visit. That way you will know exactly what products your insurance company will pay for and how many of each you may receive without additional charges.
Medicare will pay towards:
- One silicone breast prosthesis every two years (per side)
- Up to two leisure breast forms (good for swimming/exercising) per year
- Up to four mastectomy bras per year
- Any additional supplies needed due to a drastic weight change
|
