What you need to know about paying for your device
Whether it’s a new or upgraded prosthesis, orthosis, wheelchair, or other mobility assistive device,
Ottobock can help you move through the insurance or reimbursement process.
Check out these 5 tips for getting the device you need.
1. Be organized
Keep a file. Any payer or insurance will want documented information about your disability, medical treatment, income, living expenses, dependents, employment, and more. If you keep everything organized, it will prevent delays and make sure your information is complete.
2. Work closely with your health care team
Whether it’s your physician, your prosthetist, your orthotist, your therapist – your health care team is critical in helping procure payment for your first – and future –devices.
Most funding sources (public or private insurance companies, government funders, etc.) will require documentation (an exam, notes from a visit, a physical) that justifies the “medical necessity” of the device before funds are released to you.
For prosthetics, the documentation must show your current level of function or activity as well as your expected or potential level, once you have the device. It can also describe how the device will help in your employment or increase your independence.
[If you’re a lower-limb amputee, watch Levels of Function to learn why your activity level can determine the device you receive]
For orthotics, the documentation must describe your functional limitations and a history and prognosis of the weak or deformed (injured or diseased) body part.
For mobility assistive devices, mobility limitations of mobility-related activities of daily living (MRADL) should be documented. Some policies may also require a home assessment, a face-to-face visit with your treating physician, and documentation of past mobility assistive devices.
Based on your health care team’s evaluation, your physician will give you a prescription for what you need. Be sure to keep the name of the make, model, and manufacturer in your file.
3. Take time to understand your insurance plan or payment options
Ask your insurer for a copy of the plan’s Summary Plan Description (sometimes called Summary of Benefits). Review it closely. You should also check your deductible and maximum out-of-pocket, allowed amount covered for assistive devices, and if there are annual or lifetime caps. If there are sections you don’t understand, contact your health plan and ask questions. The Summary Plan Description tells you what services your plan will pay for, what it will not pay for and the amounts you will need to pay. If you are not insured, talk to your health care team. Other sources of funding may be available. If you receive a denial from your insurer, don’t give up – make an appeal.
Get informed about:
- Services your insurer will pay for and will not pay for
- Amounts you will owe
- Referral procedures
- Payments for out-of-network services
- Who to contact if you have a dispute about coverage
- Procedures for settling disputes about coverage
- If there’s a time limit on appealing a plan’s decision
4. Be persistent and don’t give up
If your request for payment is denied, make an appeal.
Homework for you
- If you did not receive a copy of the denial letter, request a written copy of the reason for denying the claim. This can be done by contacting your insurance provider’s customer service department. Review the letter and ask “Why specifically was the claim denied?”
- If you were denied for missing documentation, ask “What was missing?” Work with your health care team to get the documentation needed.
- If your submission was denied because the device was “not medically necessary/experimental,” ask the insurer/payer to define those terms. Together with your health care team, gather the documentation or clinical studies needed to counter the denial.
- Ask your insurance company for a copy of their medical coverage policy.
- Ask what documentation you will need to send them in order to receive a favorable decision.
- If the insurer’s customer service cannot provide answers for you, ask if they have a patient advocate/advocacy department that can help you
The appeal process
Many times your physician or practitioner or other health care provider will be the one writing the appeal (sometimes they may require permission from you) but there are times when only you (the beneficiary) has authorization to appeal. If you are the one making the appeal, here is what you will need to do:
- Request copies of your medical records (from your prosthetist, physicians, therapists, rehabilitation facility, hospital, home health, etc.) to support your case.
- Prepare a cover letter.
- Restate the reason why the claim was denied.
- Quote their policy and why you disagree (if applicable).
- Include a bulleted list detailing the attached documentation.
- Lead them down the path to the proof of why you think the claim should be paid.
- Follow the instructions provided with your Explanation of Benefits (EOB).
- You must submit each appeal within the stated timeframe.
- Generally, you will be allowed 1-2 appeals with the insurance company and then depending on your plan, an external appeal may be an option.
- If you don’t receive instructions, contact your insurance provider as soon as possible to avoid missing deadlines.
Even if you are the one who must make the appeal, your health care team is still a great resource for you, since they have had experience with the appeals process.
5. Stay informed about what works best for you
If you are newly disabled …
If you need to upgrade from old or outdated devices …
If your disability or ability level has changed …
If you hear about new technology that might increase your function or independence …
… talk with your health care team (therapist, physician, practitioner) to understand the features you need in an assistive device. Continue to stay in contact with them even after you receive your first device. Your team will help you get the most out of your assistive device as you have more experience with it. Sometimes you may think the device “isn’t working” but it may simply need an adjustment.
You should also contact your team if your needs change or to ask if new technology is appropriate for you.