Amputees who need orthotics or prosthetics (O&P) should ask a lot of questions before buying health insurance. Asking questions now helps avoid problems later. Problems can happen when insurance does not cover (pay for) certain O&P items that you thought it would. Or if you have to pay all O&P bills now and later get reimbursed (paid back) from the insurance company.

You can help prevent problems like these by asking a lot of questions before you buy health insurance. Here are some you might want to ask.

“Are members of the financial review board experts in O&P?”

Many health insurance policies have financial review boards that decide how much to pay for certain services, such as O&P. While review board members may include doctors and nurses, these members might not be experts in O&P. As a prosthetist, I have talked with many review board members who do not seem to really understand the needs of amputees.

“Does the financial review board include O&P advisors?”

In my opinion, financial review board members could benefit from having O&P advisors. These advisors could help in many ways such as setting realistic reimbursement rates. Now, many health insurance companies set annual (yearly) rates that are much too low. For instance, an insurance company might pay only $2,000 or less a year for a prosthesis, orthosis, and replacement parts. Those of us working in prosthetics know that this is not enough to cover the costs.

“What is the yearly reimbursement coverage and how is it determined?”

Reimbursement means getting money back for expenses that you have already paid. Most insurance companies expect the client (you) to pay the bills first and then fill out paperwork to request reimbursement.

I know of many clients who cannot afford to pay for O&P. So they may ask their service provider (such as a prosthetist) to bill the insurance company and then wait for a reimbursement check. This can cause problems, as when:

• The service provider bills the insurance company after the services have been given. Then, the insurance company determines (decides) how much the reimbursement rate will be. Sometimes this rate is much less than the amount billed.
• If the reimbursement rate is less than the cost of O&P, the service provider will ask the client to pay the difference. Many clients are shocked by how much money this can be. Clients have said to me, “If I had known that the insurance company was not going to pay the full amount, I would not have agreed to have these services.”

“Can I have an estimate of how much the reimbursement will be?

When amputees ask how much the insurance company will pay for O&P, the company may simply say, “Oh yes, we cover those services.” But this answer is not good enough.

In my opinion, insurance companies should give a detailed estimate of how much it will pay for O&P items and services. But many insurance companies refuse to do so. Instead, they say that reimbursement is determined only after the financial review board reviews the bill from the client or service provider.

About the Author

Raymond Francis is a licensed, certified prosthetist with more than 40 years of experience in the O&P industry. He is the chief prosthetist for Ohio Willow Wood.

Translated from Dealing with Insurance Companies Questions They Would Rather You Not Ask
http://www.amputee-coalition.org/inmotion/jul_aug_06/dealing_with_insurance_co.html