Details are Critical for Reimbursement of Therapeutic Shoes

Until there is bureaucratic relief, the best way to get paid for
therapeutic shoes is to pay attention to the details within a flawed system,
according to a presenter at the American Orthotic & Prosthetic Association
(AOPA) National Assembly in Las Vegas.

Joe McTernan, director of
coding & reimbursement services education &
programming for AOPA said that the last Medicare prepayment review report on
diabetic shoes had a 99% error rate – meaning that only one of 100 claims
had all the documentation and should have been paid properly.

“That is not a symptom of a fraud problem,” McTernan said.
“That is not a symptom of a poor documentation problem. That is a system
problem and that is the approach we’re taking.”

He said that AOPA agrees with the complaints that documentation
requirements are simply unreasonable, and the organization is working at the
highest levels of the Centers for Medicare and Medicaid Services to try to get
relief for its members.

“[Therapeutic] shoes have always been an area for fraud,” he
said “There’s got to be an easier way for legitimate providers to
provide that service.”

Tips for reimbursement

McTernan offered 10 practical tips for getting reimbursed for
therapeutic shoes:

1. Make sure patients actually need the benefit.

“When the patient comes into your office asking for diabetic shoes,
make sure they are eligible,” he said.

That may sound simple, but many patients base their requests on the
calendar, rather than the need. One pair of shoes and up to three inserts per
calendar year is the benefit maximum; it is not a Medicare guarantee, he said.

“If those shoes remain functional, then there is no benefit. They
should bring the shoes they’re wearing to every appointment,” he

2. Work with your certifying physician.

McTernan encouraged providers to inform physicians about their role and
make sure they complete the required certified statement.

“Without it, you’re dead in the water,” McTernan said.

If providers think some requirements are extreme, McTernan asked them to
consider one – an in-person visit with the certifying physician within 6

“Is it really that unreasonable a requirement?” McTernan said.
Shouldn’t they [diabetic patients] be seeing the physicians managing their
diabetes at least twice a year?” he asked.

He also suggested in-services to educate physicains on the required

“Used to be you could circle the boxes and they would sign –
no more. They have to physically fill out the form,” McTernan said.

3. Pay attention to referring practitioners.

While therapeutic shoes may be prescribed by non-physician practitioners
(physicians assistants, nurse practitioners, podiatrists, etc.), only the
physician (MD or DO) who is treating the patient’s diabetes may sign the
certifying statement.

“It must be an MD or DO,” McTernan said.

McTernan advised also sending the referring physicians letters about
increased Medicare documentation requirements.

Importance of documentation

4. Document in-office visits.

McTernan warned providers not to overlook small yet critical details on
the claim forms.

“Don’t lose the claim because of something you have control
over. Don’t lose the claim over something you didn’t do,” he

5. Check the Pricing Data Analysis and Coding product classification

“Don’t give up easy money. It takes about 35 seconds to check
the manufacturer to make sure their products are on the list,” said
McTernan. “If they’re not on the list; don’t use them. Or call
them and tell them to get put on the list.”

6. Remember, you are a health care professional.

McTenan said that providers should document patient weight and changes
in condition.

“Nobody ever documents weight and height. How many of you do blood
pressure? Why not?” McTernan asked. “It’s all part of your
overall professional care. Are we suppliers or are we health care
professionals? Do the things that other health care professionals do and then
use that documentation to support your claim.”

7. Gather all documentation before delievery of service.

This gives providers the opportunity to consider an Advance Beneficiary
Notice if the documentation is not collectible or not available, he said.

8. Educate patients.

Patients can be the strongest advocate out there.

“AOPA can scream from the top of Capitol Hill all day long,”
McTernan said. “When this [issue] is going to get some real action –
and it’s coming – is when it becomes an access-to-care issue for the

9. Don’t give up.

“The issue is about fighting for reimbursement because you’ve
worked hard to provide a good service, good quality, good care and in good
faith. And no matter what, you have to be your own advocate. You have to fight
for that service if you expect – going forward – to be paid,” he

10. Consider appeals.

McTernan advised taking an appeal as far as one can.

“I cannot tell you the value of the administrative law judge level
of appeal — the third level of appeal. When it gets to them and it’s
common sense and you show good faith effort and show that you provided a
quality service, they are 100 times more reasonable than the contractors who
are bound by their own policy and fighting against you,” he said.

He reminded providers that similar appeals also can be bundled. If one
makes the same argument and wins, then all the bundled claims win.
Charles Wray

For more information:

  • McTernan J. Top 10 strategies for getting paid for therapeutic
    shoes. Presented at the 2011 American Orthotic & Prosthetic Association
    National Assembly. Sept. 19-22. Las Vegas.

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