SUCCESSFUL TORONTO CHIROPODIST SHARES GREEN SHIELDS ORTHOTIC DISPENSING GUIDE LINES
posted: Feb 11, 2014.
New Orthotics and Orthopedic Footwear Policy Coming January 1, 2014
Orthotics and orthopedic footwear are highly utilized benefits in many group benefit plans. Unfortunately, they are also subject to fraud, abuse and misuse. Because of this, GSC conducted an extensive analysis of claim trends for orthotics and orthopedic footwear over the past several years. What did we find? There has been a steady increase in the number of orthotics and orthopedic footwear claims processed and reimbursed by GSC during the study period.
Why is this happening?
Orthotics and orthopedic shoes tend to be overly prescribed and improperly dispensed by providers and retail- ers who are not foot specialists and for non-medically necessary purposes that are not intended to be covered under benefit plans. Many providers and retailers are selling inserts or shoes that are marketed as “orthotics” or “orthopedic”, but do not meet benefit eligibility requirements. While this footwear may provide plan members with some comfort and support for their feet, they are not medically necessary and are not eligible expenses under your group plan.
What is GSC doing about it?
Orthotics and orthopedic footwear benefits are meant to provide coverage for plan members diagnosed with medical conditions that affect their feet and who require specialized footwear to treat their condition or to assist with mobility. In other words, orthotics and orthopedic footwear must be medically necessary in order to be eligi- ble for reimbursement under your group plan.
Effective January 1, 2014, GSC is implementing a new standard adjudication policy for orthotics, orthopedic footwear, and custom footwear claims. Please note: if your benefit plan already has an orthotics/orthopedic shoe policy, the relevant rules of GSC’s standard policy will not be applied to your plan. What does this mean? For ex- ample, if your policy allows other providers to dispense orthotics, GSC’s rules on eligible dispensers will not take effect. However, if your policy does not stipulate what documents need to be submitted with an orthotics claim, GSC’s standard documentation rules will apply.
In this edition of The advantage, we’re providing you with a short overview of the upcoming changes. We will be sending you another special edition of The advantage closer to the effective date which will include a detailed list of the specific claim submission requirements for each benefit as well as a plan member communication to assist you in communicating these changes to your plan members.
Starting on January 1, 2014, plan members who submit claims for orthotics, orthopedic footwear, and custom footwear will be required to:
1. submit new documentation with their claim;
2. ensure that their provider is eligible; and
3. meet specific medical criteria. Only those orthotics, orthopedic footwear, and custom footwear that are prescribed to treat a recognized medical condition will be eligible for reimbursement.
In addition, the following claim submission rules will be applied:
New Claims Rule:
Custom Orthopedic Custom Orthotics Footwear Footwear
Prescription from an eligible medical professional with the medical diagnosis necessitating the orthotic/orthopedic shoe included on the prescription.
A copy of the biomechanical examination or gait analysis.
An itemized receipt indicating the date of pick up and that payment has been made in full.
The receipt must include the make and model of the orthopedic footwear. A description of the casting technique used to create the orthotic.
Plan members must go to an authorized prescriber to obtain a prescription for their footwear:
Plan members must go to an authorized foot specialist to have their footwear dispensed:
• Orthotist • Pedorthist
Claims for children under the age of 5 are ineligible.
What’s not covered?
Orthotics purchased solely for comfort, for sports or recreational activities, stock items, off-the-shelf and prefabricated devices, soles or inserts (e.g., Dr. Scholl’s) are not eligible. Having plan members walk on an ink pad or pressure pad to provide a prefabricated sole or insert is not considered custom made orthotics. Off-the-shelf walking or sports shoes marketed as orthopedic, sandals, comfort shoes without prescription for a medical condition, shoes purchased specifically for sports or recreational activities are not eligible. Claims for these types of devices or footwear will be denied.
What about my plan members? How is this being communicated to them?
We recognize that GSC’s new orthotics and orthopedic footwear policy will
impact your plan members as claims that we may have accepted in the past will
no longer be eligible. In our November Special Edition of The advantage we
will be providing you with a separate communication for your plan members
that will include a FAQ and Claim Submission Checklist. We will also be posting
this information on our website and Plan Member Online Services in an effort to get the word out to your plan members.