Frequently Asked Insurance Questions

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 Frequently Asked Insurance Questions Frequently Asked Insurance Questions insurance 3906680 640 e1565030101638have 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.

Supporting Matthew 25 Ministries

Matthew 25 Ministries Global Village matthew 25 Supporting Matthew 25 Ministries Matthew 25 Ministries0004For many years we have been giving gently-used braces to Matthew 25 Ministries. Their headquarters are right down the street, but their services reach people all over the world. Matthew 25 Ministries is a multi-faceted not-for-profit organization that serves more than 20,000,000 people each year.

They collect more than just braces. They accept other medical equipment like crutches, bandages, and gauze as well as school supplies, clothes, shoes, personal care items (shampoo, lotion, toothpaste, etc), cleaning supplies, household items (blankets, tote bags, etc.), Kitchen supplies, baby needs, food, paint, hospitals supplies.

Matthew 25 Ministries  matthew 25 Supporting Matthew 25 Ministries Matthew 25 Ministries0003With all of these items being received at their Kenwood Road location, they recently expanded to be able to accept and ship out more items and hold more volunteers. This new facility was built with efficiency in mind. 43% of the energy used is created from solar energy! M25M recycles all of its own paper, plastic, and cardboard; as well as all fabric and clothing that’s deemed unusable.

matthew 25 Supporting Matthew 25 Ministries Matthew 25 Ministries0002Volunteers get a tour of the facility that includes a simulation of a third-world village. They encourage volunteers of all ages! They even have a system in place for volunteers under 8 years old! If you want to support Matthew 25 Ministries, there are a lot of ways to be involved. They also have a 5K to raise money for their work in the United States and abroad!

We wanted to express how honored we are to support Matthew 25 Ministries and share their mission with others. Here are some resources for you in case you would like to learn more!

  • Matthew 25 Ministries ~ www.m25m.org ~ 11060 Kenwood Road, Cincinnati, Ohio 45242 ~ 513-793-6256
  • Hunger 5K ~ www.hunger5k.org ~hunger5k@m25m.org

Matthew 25 Ministries matthew 25 Supporting Matthew 25 Ministries Matthew 25 Ministries0001

 

 

So You Have a Foot Orthotic Prescription?

foot orthotic So You Have a Foot Orthotic Prescription? run 1499362 1280You 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 foot orthotic So You Have a Foot Orthotic Prescription? cincinnati foot orthotics

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 foot orthotic So You Have a Foot Orthotic Prescription? Bioworks Foot Orthotics Timeline

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.

Ulnar Collateral Ligament – Elbow Surgery (Tommy John)

Learn about UCL Elbow Surgery elbow surgery Ulnar Collateral Ligament - Elbow Surgery (Tommy John) Baseball PitcherElbow Surgery (Tommy John) – Ulnar Collateral Ligament

Contributed by Stephanie Thomas, COF

To coincide with 2017 Opening Day, we decided to shed some light on a procedure we see quite often that is related to baseball and more specifically pitchers. In fact, a professional pitcher was the first person to have this elbow surgery about 40 years ago.

Who is Tommy John?

In 1974 Los Angeles Dodgers’ pitcher Tommy John was having a great 11th season in the Majors, starting 13-3. Many believed he would eventually be a Cy Young Award winner, but he damaged his ulnar collateral ligament (UCL), which is a ligament of the elbow. He was adamant about returning to baseball. John went to the team physician, Dr. Frank Jobe and asked him to develop an elbow surgery that would fix his UCL and allow him to pitch again. Dr. Jobe developed a technique that allowed John to return to pitching in 1976. Since then there have been different techniques developed to help repair the UCL.


Original Procedure – During Dr. Jobe’s procedure, he would harvest the patient’s palmaris longus in the wrist. It is important to note that not everyone has a palmaris longus; if the patient doesn’t have this ligament the surgeon may opt to harvest a different autograft (from patient’s body) such as the gracilis, plantaris, or a strip of the Achilles to complete the elbow surgery.[1] You can test yourself by touching your thumb to your ring finger and twisting your wrist. The ligament will pop out (like the photo) if you have it.

Ligament used for Elbow Surgery elbow surgery Ulnar Collateral Ligament - Elbow Surgery (Tommy John) ligament in arm for elbow surgeryDr. Jobe utilizes the Figure 8 technique where he would drill two holes in the medial epicondyle and two holes into the ulna and feed the palmaris longus through. Then he would suture the tendon to itself. He also had to detach the flexor-pronator musculature at its origin which would cause the ulnar nerve to transpose.[2]

Docking Technique – This technique, developed by Dr. David Altchek, it is different from the original technique in many ways. First it does not detach the muscle group, instead, it uses a muscle splitting technique. This procedure also does not drill as many holes, and the tendon is shaped into an “elongated D” instead of a figure-8. The tendon graft enters the humerus but never exits and is sutured to the bone.[3]

What are the Signs and Symptoms of Ulnar Collateral Ligament Injury?

You may feel a “pop” on the inside of the elbow that is accompanied with pain and possible swelling. You could also notice that you are weaker when throwing. Always make sure you have your injury evaluated by a healthcare professional; an MRI may be ordered to determine if there is a tear in the ligament that requires elbow surgery.

Who should have “Tommy John” elbow surgery?

Surgical intervention should be discussed with your physician. There are conflicting ideas on how early is too early to for an athlete to have this procedure. Many believe that high school athletes should not have the surgery due to some athletes still growing, where others believe it is ok. You should also ask the doctor what type of technique he/she will be performing.

Treatment and Rehabilitation

If you decide to have “Tommy John’s” elbow surgery, you will be placed in an elbow range of motion orthosis, after the procedure, (we use the Breg T-chek, seen below) to help protect the elbow and to eliminate movement. The orthosis is also adjustable to allow for a controlled range of motion. When the time comes, you will begin physical therapy and rehabilitation to get back to throwing again. This whole process can take over a year. Discuss the timeline with your doctor.

 

Our specialists can answer questions about the The T-chek Brace

Just call us or complete our contact form and we’ll get back with you within 24 hours.

References

[1] Ellattrache N; Harne C; Mirzayan R; Sekiya J. Surgical Techniques in Sports Medicine. Lippincott Williams and Wilkins. 2007.

[2] Vitale M. Ahmad C. The Outcome of Elbow Ulnar Collateral Ligament Reconstruction in Overhead Athletes: A Systematic Review. Am J Sports Med. 2008;36:1193-1205.

[3] Borak T. Ulnar Collateral Ligament Reconstruction: A Look Inside Tommy John Surgery. The Surgical Technologist.2009;41:163-172.

3 Tests to find the Best Shoes

3 Tests to find the Best Shoes

When you can’t get orthotic shoes from a specialist, you can use these tests and choose the best shoes to support your feet and provide the best support for your knees, your back, and your posture.

Tammy Daulton, Our Licensed Pedorthist has simplified this process with 3 easy tests to select the best shoes:

  1. Get the Best Shoes best shoes 3 Tests to find the Best Shoes best shoe test collageHeel Test – Hold the shoe in both hands; place one hand on the bottom of the front of the shoe.
    Push the heel of the shoe toward the inside of the shoe with the other hand. If the heel is easy to push down it won’t provide good support for your heel. The best shoes have a sturdy heel to support the entire foot and ankle.
  2. Toe Test – Hold the shoe in both hands; place one hand at the toe of the shoe and one and on the heel of the shoe. Push the toe of the shoe up to try to bend the front of the shoe up. If the shoe is easy to bend anywhere but where the toes meet the foot, it will not provide good support. The best shoe will have very little bend anywhere but right where the toes connect to the rest of the foot.
  3. Twist Test – Hold the shoe in both hands with one hand gripping the heel and one hand gripping the bottom of the front of the shoe. Twist the heel to the right while twisting the front of the shoe to the left. The best shoe will be difficult to twist. If the shoe is easy to twist it will not provide good support.

The next time you go shoe shopping, take these tests with you to choose the best shoes. These tests will help you find shoes that will reduce foot and knee pain caused by wearing non-supportive shoes.

If you have any questions about choosing the best shoes you can send an email to contact@gobioworks.com.

 

Plagiocephaly and Cranial Remolding Helmets

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 plagiocephaly Plagiocephaly and Cranial Remolding Helmets Top View 3 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  plagiocephaly Plagiocephaly and Cranial Remolding Helmets Front View 3 Helmets

*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.

Understand Health Insurance and Durable Medical Equipment

Understand Your Health Insurance  health insurance Understand Health Insurance and Durable Medical Equipment Save money by understanding your health insurance e1481556849589Bioworks is eager to help you save time and money and make optimal use of your health insurance. However, with the complexity of health insurance policies today, and the constant changes made by insurers and employers, keeping up-to-date on every policy is difficult for us. When possible, we do let you know what we know about certain carriers or policies, even when a certain product or services is not covered.

So we are encouraging you to understand the limits and requirements of your health insurance. This is critically important when you are or a family member is referred to a durable medical equipment (DME) supplier.

How Health Insurance Deals with DME

Many DME referrals require prior authorization by your insurance company, which means that your insurance company may reject the cost of the merchandise provided to you, unless they have been notified and provide approval in advance. Many carriers no longer allow you to obtain the DME before notifying them and get authorization later. Many insurances are denying these “retroactive” authorizations.

Not only do virtually all insurance companies differ in their requirements and coverage, but their policies and procedures are constantly changing. We strive to contact all insurance companies prior to you receiving your item, that way we can have your claim processed properly and the best way for you. While we try our best to keep current with developments in health insurance, you are the only person who can know everything about your particular policy at any given time and with particular treatments are equipment.

How You can Avoid Health Insurance Issues

Please review your policy and become familiar with all its requirements. Call your insurance carrier whenever you are going to the doctor or you are anticipating needing to make a DME claim. Our insurance and billing staff will be available to you as you need services and DME from Bioworks.

Some Things to Remember about the Billing Process

  • Prior Authorization does not guarantee payment.
  • If insurance tells you an item is a covered benefit, that still does not guarantee payment; insurance companies must first determine medical necessity before paying the claim.
  • Claims are not submitted until item is received (that is your bill date).
  • We must have a prescription prior to billing insurance but that does not prove medical necessity; insurance companies have their own stipulations.
  • If you claim does get denied we can offer you percentage off of your bill.
  • We will also work with you and the insurance company for any appeals that need to be done for denied claims.
  • If your claim is applied towards your deductible or co-insurance, we can not take any additional amount off of your bill.

If you have any questions, call us at 513-793-7335. Thank you!

The BIoworks Staff

photo credit: www.freeimages.com, photographer Marcelo Moura

Carpal Tunnel Syndrome: Is Surgery My Only Option?

What is Carpal Tunnel Syndrome?

Carpal Tunnel Syndrome carpal tunnel Carpal Tunnel Syndrome: Is Surgery My Only Option? wrist pain 5 1411498The 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 carpal tunnel Carpal Tunnel Syndrome: Is Surgery My Only Option? carpal tunnel movements

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 Syndrom carpal tunnel Carpal Tunnel Syndrome: Is Surgery My Only Option? Grip Strengthening for Carpal Tunnel e1482123991998Strengthening: 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 carpal tunnel Carpal Tunnel Syndrome: Is Surgery My Only Option? carpal tunnel syndrome relief
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)