"The difference between the right word and the almost right word is
the difference between lightning and the lightning bug."
~ Mark Twain
W
hen Mark Twain wrote
those words, he was giving
counsel to writers, but he
could just as easily been
advising on how to write
a “bulletproof” insurance claim. The only
difference is that in the insurance business,
the difference between the right word and
the almost right word is the difference
between the approval and denial of your
claim.
Running a successful pedorthic practice involves many
challenges – ensuring your patients receive the level of care they
need to remain or become ambulatory, managing your time to
handle staff, patients and colleagues, and striving to keep your
practice running efficiently enough to realize a good financial
outcome. Dealing effectively with insurance claims is one of the
ways to keep your practice running smoothly for you and your
patients.
Know Your Role
The secret to writing a successful claim is essentially simple. Be
clear. Be precise. Be diligent. And keep communication open.
In most claims there will be the patient, the physician, the
pedorthist, and the insurer. In some cases there will be a
therapist or other health care providers depending on the
complexity of the condition being treated. In all cases, everyone
involved has to be a part of the team, and it is critical to ensure
that everyone involved understands their roles on the team,
and that they keep everyone informed in as clear and precise a
manner as possible.
The Insurer’s Role
The insurance company provides the policy that uses precise
language to specify what will be covered. Insurers are not in the
business to deny coverage – they would not remain in operation
long if they rejected every claim that crossed their desks.
But they are in the business of being prudent. They will evaluate
the claim based on the terms in the policy – does the condition
warrant treatment by a pedorthist? Does it require orthotics? Is
the proposed treatment consistent with the diagnosis?
It is vital to remember in dealing with insurers that they
have to be on the watch for benefit fraud as a matter of
protecting themselves. There are also claims that have been
filed incorrectly through some misunderstanding, or because
physicians are not clear on what to write on a prescription. If a
GP writes a prescription for “custom modified orthotics” when
the policy specifies coverage for “custom molded orthotics,”
the insurer will deny the claim because the prescription is not
consistent with the coverage.
The Patient’s Role
Since it is the patient who owns the policy and is receiving
the treatment, it is critical that the patient knows the policy. A
doctor deals with many patients and insurance companies and
he or she may not be familiar with all the specifics of a patient’s
health insurance coverage, so it is vital for the patient to become
familiar with the policy.
It is the patient’s responsibility to read and understand the terms
of the coverage, and obtain the necessary forms for filing. In
some cases, this can require the involvement of an insurance
agent or a benefits administrator to provide advice and assistance
in completing the forms accurately, and promptly. There may
be time constraints on a claim, which should be outlined in the
policy.
The Doctor’s Role
The doctor, who may be a general practitioner or a specialist,
will need to diagnose the patient’s condition accurately, and
prescribe the proper treatment for the diagnosed condition. This
is one area that can result in confusion that can deny a claim.
GP’s may not have the specific training to understand exactly
what to write on a prescription, for example, prescribing a
“modified insole” for a patient, when the language in the policy
covers “custom molded orthotics.”
Current Pedorthics
March/April 2013
35