Frequently Asked Insurance Questions

by | Aug 5, 2019 | health insurance, insurance coverage

With these uncertain times when it comes to health insurance, there are always questions about cost and coverage. We want to know: how much am I going to have to pay for a particular service? This is a very valid question. I have compiled popular questions (with answers) that I have had patients ask me in regards to their insurance. I hope these answers will help you!

  1. WHAT IS A DEDUCTIBLE? You’re deductible is the amount you have to pay before insurance will start paying their portion (I have seen deductibles range from $0 to $5,000 per person). Once you have accumulated your deductible, then usually your co-insurance kicks in.
  2. WHAT IS CO-INSURANCE? Co-insurance is the percentage that insurance will pay once your deductible has been met. The most common amounts I have seen are 80% insurance responsibility, 20% patient and 90% insurance responsibility and 10% patient.This of course varies insurance to insurance and plan to plan. Co-insurance usually does not apply once the out of pocket max has been met.
  3. WHAT IS OUT OF POCKET MAX? The out of pocket max, is the maximum amount that you pay for the plan year (usually January 1 to December 31). Once this is accumulated then insurances usually pay 100% of expenses as long as it is medically necessary. Usually the out of pocket includes the deductible amount and the co-insurance you have been paying. 
  4. WHAT IS AN AUTHORIZATION? Some of our items do require, what is called an authorization. This is just letting the insurance know that a particular brace or product has been prescribed for you and that we (Bioworks) are going to be the providers. The insurance then just makes sure it is a covered benefit under your plan. Most insurances require us to obtain authorization prior to services being rendered. There are some instances that a brace is needed right away and we can try to obtain authorization after the fact.*Note that authorization does not guarantee payment, it just determines that it is a covered benefit; the claim still needs to go through medical review*
  5. MY INSURANCE SAID MY SERVICE WAS COVERED, WHY WAS MY CLAIM DENIED? Claims can be denied even if the item is a covered benefit because the insurance processes it under their medical review. For example you may be prescribed a custom ankle brace from your doctor and that particular code is covered under your plan, but after medical review, insurance may find that for your particular diagnosis, a custom ankle brace is not warranted.
  6. I HAD A PRESCRIPTION, WHY WAS MY CLAIM DENIED? Same reasoning as above, just because a physician prescribes a brace does not guarantee an insurance deems it medically necessary; it is all based on the plan stipulations. 
  7. IS THE PRICE YOU BILL, THE PRICE I PAY? The price that is on your paperwork is not the price you pay. We have our costs based on all the different insurance allowables. This amount allows for any contractual write-offs we have with the insurance companies. Unfortunately every single insurance and plan are different, so we are unable to give you an exact amount but may be able to guess for you. Just know that is not the price you are paying. The price also includes any adjustments/office visits needed for that particular brace or product. Typically it is a one-time charge, unless anything extra is needed. 
  8. ARE THERE DISCOUNTS FOR NON-COVERED SERVICES? We understand that not all of our services are covered under insurances. We have been able to pin point some insurances that we know do not cover particular services and yes we can give a self pay discount. This does vary based on product but we can always bill insurance, if you like, and see if they will cover; if not we can take a percentage off.
  9. DO I NEED A PRESCRIPTION? We legally need a prescription in order to bill insurance; this also gives us direction as to what your physician is wanting. But keep in mind that having the prescription does not dictate medical necessity/covered service, just gives us the right to bill insurance. 
  10. WHAT CAN I DO IF MY CLAIM IS DENIED? You have the right to appeal any decision made by the insurance. We are here to assist in any way for the appeal.

Things to Remember!

Prior Authorization does not guarantee payment.

Covered benefits does not equal payment; always based on medical necessity.

Prescription is needed in order to bill insurance.

If claim is denied we can take a percentage off of your bill.

If claim is applied towards deductible/co-insurance we can not apply anymore discount.

So You Have a Foot Orthotic Prescription?

by | Aug 10, 2017 | foot pain, health insurance, knee pain, orthotics

You go to the doctor for foot, ankle, or knee pain and he gives you a custom foot orthotic prescription. What is the next step? Give us a call! Bioworks accepts most health insurance plans and some insurances cover foot orthotics. We can help start you on the road to recovery. Foot orthotics do require at least two appointments with one of our certified orthotists or pedorthists.

What to Expect at Your Foot Orthotic Evaluation:

If your physician prescribes you custom foot orthotics, it is a two-step process. First you come in for a no cost evaluation. Our orthotist or pedorthist will evaluate your feet, watch you walk, and discuss the goals you would like to achieve. At this appointment, we will also discuss insurance; there are certain insurances we know will not cover orthotics (Humana and Medicare), but do not fret we do offer orthotics at a discounted rate. We bill insurance between $400 and $450 depending on the orthotic received. We also allow for patients to go on payment plans; it’s never a set payment, just what you feel comfortable paying that month.

Once you have your evaluation you do not have to have the orthotics fabricated; we can check your benefits, call you with the information, and then you can decide. If it is not the right time for you to get them or if you just don’t think orthotics will work for you, there is no charge for anything. We only bill insurance or you, if a product is received. The information we obtain from your evaluation is good for 3 months before you would have to come in for another evaluation. If you would like us to bill insurance we will need a prescription from your physician.

See an Orthotist for Plantar Fasciitis

What to Expect at Your Foot Orthotic Fitting:

Fitting usually takes place between 1 or 2 weeks of the evaluation, depending the orthotics fabricated. We ask that you bring the shoes that you wear the most. We will take those shoes into our lab and grind the length of the orthotic to fit inside. Next, we will have you walk and make sure they feel comfortable. If there is something that is uncomfortable, we can fix it right then and there. Once you are fitted for the orthotics, we suggest weaning onto wearing them all day. This may    take a couple weeks, it could take a couple days.

 

What to Expect After Your Fitting:

Depending on your activity level, your orthotic may wear down and feel different than when you were initially fit. We offer free adjustments for the life of your orthotics. If you are wearing them and something doesn’t feel right or you are getting blisters, give us a call and we will gladly set you up with an appointment for an adjustment. Most orthotics should last 2-3 years, depending on your activity level. If your top cover has worn away and it has been less than a year, we will replace for free; if it has been over a year it is a $25 self-pay charge.

Bioworks Foot Orthotics

Walking around with foot, ankle, and knee pain is never fun. Let us help you gain a pain free lifestyle. Give us a call at (513)793-7335 or fill out our appointment request online and we can get started today!

 

You can request a foot orthotics appointment if you have a prescription from your doctor.

We’ll confirm your request within one business day.

Submit Appointment Request

Plagiocephaly and Cranial Remolding Helmets

by | Jan 25, 2017 | orthopedic, pediatric

Cranial Remolding Helmets for plagiocephaly have become more and more in demand since it has been known that it is safer for an infant to sleep on his/her back. During the early stages of development, the skull is vulnerable to any outside pressure, causing it to change shape. My hope is to educate you more on what to expect if your pediatrician/specialist has recommended or prescribed your child a Cranial Remolding Helmet and answer any questions you may have.

When is a cranial remolding helmet necessary?plagiocephaly and cranial remodeling helmets

A doctor or specialist typically prescribes a helmet because the child has been diagnosed with the following:

  • Plagiocephaly: typically the result of torticollis of the neck and the infant is usually laying with their head always to the same side
  • Brachycephaly: caused by infant laying on his/her back and the back of the head becoming flat
  • Scaphocephaly: infant’s head is constantly rolling side to side, causing the head to be elongated

If your child is diagnosed with plagiocephaly, brachycephaly or scaphocephaly, therapy may be prescribed for infant, as well as changing of the sleeping arrangements. Both of which should be discussed with the pediatrician/specialist.

At what age does a child wear the helmet?  

Most of the infants we see range in age from three months to nine months. The younger the patient the more potential there is for head growth during the therapy. Since there is more growth at a younger age, the child may not have to wear the helmet quite as long as they may have if they were older. Another factor to consider is that older children have a greater ability to grab and possibly remove the Velcro® strap holding the helmet together (Note: helmet will not fall off if the strap is removed but will not be closed completely).

Does Insurance Cover cranial remolding helmets?*

It is very common that insurances do require conservative treatment before they will provide coverage for the Cranial Remolding Helmet. They typically require at least six weeks of conservative treatment which can include re-positioning in the crib and therapy. Therapy can include a physical therapist and/or occupational therapist stretching the neck muscles so the infant does not tend to turn to one side or the other.

Insurance also bases coverage on whether or not the measurements of the infant’s head fall into the moderate to severe range on the Cranial Vault Asymmetry Index (CVAI). If your child’s measurements are in that range then there is a good chance the helmet will be covered. These measurements would be taken at your first evaluation (which is free!).

What does an appointment entail? 

During your first appointment, we go through the history of the pregnancy; we also ask about any complications during delivery. After the history is taken, then measurements of the head are recorded.  Next, a stockinette is placed on the child’s head and the orthotist uses a laser scanner around the head to obtain a 3-D picture.

Based on the measurements, we then decide if a helmet is necessary; if not, we can set up another appointment to re-evaluate and see if the condition has worsened. The scans are only viable for 2 weeks; after that time, if a helmet is to be ordered, new measurements and scan must be obtained. Once the measurements and scan are collected and the child’s measurements fall in the moderate-to-severe range. then we order the helmet.

How is a helmet fitted? 

Once the helmet has been received from Boston Brace, we set up the fitting as quickly as possible. After the first fitting, we setup up bi-weekly appointments for either new measurements and/or scans to check progress. Adjustments of the helmet are then made at that time. Typically the helmet is not needed once the patient has measurements in the mild-to-moderate range and/or the parents are satisfied with the results.

Baby helmets for plagiocephaly

*All helmets require a signed prescription from a physician or specialist. Coverage is based on individual plans and may be subject to a deductible.*

We are glad to answer your questions about plagiocephaly and other conditions that are treated with Cranial Remolding Helmets.

Please allow 24 hours for a reply.

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Carpal Tunnel Syndrome: Is Surgery My Only Option?

by | Dec 1, 2016 | hand issues, orthopedic

What is Carpal Tunnel Syndrome?

Carpal Tunnel SyndromeThe carpel tunnel is where the median nerve, various tendons, and muscles cross over the palmar side of the wrist and hand. Since it is such small space, once one of these structures is irritated numerous problems can arise.

The most common symptoms of Carpal Tunnel Syndrome (CTS) are numbness and tingling in the hands and fingers as well as pain on the palmar side of the wrist. There are varying degrees of severity of CTS but, if found early, conservative treatment can be an option.

Is Surgery the Best Option?

Anytime your doctor mentions the word surgery, there are so many questions that need to be answered:

  • How long will I be under anesthesia?
  • What are the risk factors?
  • Will it be worth it?
  • Will it work?
  • Will I be off work? If so how long?
  • How will this affect my daily life?

With all of these uncertainties sometimes surgery does not seem to be the best option at that time. Sometimes we want to explore the more conservative treatment options because choosing to have surgery is a major decision. Depending on the severity of your symptoms, surgery may be the best way to relieve your symptoms but there are other ways to manage the symptoms of carpal tunnel syndrome and talking to your doctor about your situation will help you determine your needs.

Managing Carpal Tunnel Syndrome

The most common management of the symptoms is to wear a wrist brace. It needs to be a Wrist Cock Up Splint (WCUS) that keeps the wrist in a neutral position (slightly extended).  This will help keep the median nerve from being pinched or compressed to alleviate any irritation.  Most people wear the wrist brace(s) while sleeping since we like to flex our wrists when we are asleep. If you are having pain while awake or with activity it is okay to wear the brace(s) then.

Other treatment techniques that can help manage your pain, along with the wrist brace, are yoga, hand therapy, and ultrasound therapy. You can also use these daily movement/stretching techniques offered by sportsmedpress.com:

Help for Carpal Tunnel pain

Movement: Gently move your wrist from side to side in a handshake motion. Hold for 5 seconds on each side. Repeat 10 times. Do 3 sets.

Grip Strengthening for Carpal Tunnel SyndromStrengthening: With a rubber ball in your palm hold a squeezing grip around the ball for 5 seconds. Repeat 10 times.

Learn carpal tunnel syndrome exercises
Stretching: Place both palms on a flat surface. Gently lean body forward over your wrists and hold for 20 seconds. Repeat 3 times.

If you have questions, you can call Bioworks at 513-793-7335 or complete our <a href=”https://cryptnsend.com/bio1/bio1.php”>contact form</a>.<em> As always, you should consult your primary care physician before beginning this or any treatment or exercise routine. </em>

(Photo credit: www.freeimages.com photographer: Carpal Tunnel Gadgets)