The rising costs associated with appealing denials for orthotics and prosthetics (O&P) are becoming a significant concern for patients and healthcare providers alike. As insurance companies increasingly deny claims for these essential devices, patients often find themselves navigating a complex appeals process that can be both time-consuming and expensive.
Many patients rely on custom orthotics and prosthetics for mobility and pain management, yet the costs can range from $300 to $800 or more. Insurance companies frequently deny these claims, citing reasons such as lack of medical necessity or failure to provide adequate documentation. This trend forces patients to either absorb the financial burden or engage in lengthy appeals, which can involve additional costs for legal assistance and medical documentation.
The appeals process itself is fraught with challenges. Patients must gather comprehensive medical records and often collaborate closely with their healthcare providers to demonstrate the necessity of the denied items. This situation not only exacerbates financial strain but also contributes to emotional distress, as patients grapple with the uncertainty of their healthcare coverage.
Health plans issue two major categories of denials: substantive and technical. What are substantive denials?
Claims that are denied due to services being considered as not medically necessary for the patient or are seen as experimental in nature are substantive denials. These kind of claim denials come with the right to appeal. Providers can appeal with necessary documentation that prove medical necessity. Health plans usually mandate healthcare providers to meet specific requirements for micro-processor controlled knees and arms.
Electrically-powered prosthetics need to meet stringent medical necessity guidelines to be reimbursed. Custom-fabricated orthotics come with similar reimbursement requirements. Likewise, newer prosthetic devices are more likely to be classified as experimental by insurers.
Substantive denials can be appealed and overturned by providing the necessary documentation to establish that the prescribed treatment is not experimental by nature. It all boils down to precise clinical documentation to overturn denials and accelerate the appeals cycle.
Technical denials cannot be appealed as they are denied due to policy exclusions. These are hard denials and cannot be appealed. As technical denials are due to non-adherence to contractual obligations they cannot be overturned and will have to be written off. They do not come with the rights to appeal.
The best way to manage denials is to prevent them from occurring and draining resources. Appealing denials is a time and resource-intensive process. Providers can adopt AI powered solutions to flag claims that are more likely to be denied. By identifying denials that are high-risk before claims submission can save provider organizations the costs involved in reworking claims.
Automating the denial prevention process improves the health of the entire claims cycle. To know how to mitigate denials through the power of an AI-assisted process meet us at booth #428 at the AOPA Ignite. Our denial prevention experts will walk you through how to resolve denials in minutes within a fraction of the cost and time.
To book an appointment please fill out the form here.