Insurance/Payers

Claims Review
While Prosthetic and Orthotic claims represent a small percentage of the overall types of claims submitted for payment, they are oftentimes for large sums per claim. Working with Forensic Prosthetic and Orthotic Consulting provides the following advantages:
  • Case managers can focus on areas more frequently encountered within their expertise.
  • Receive detailed response verbiage based on submitted documentation relative to policy limitations and exclusions.
  • Claim appeal support by reviewing all documentation and responses based on medical necessity.
  • Identification of inappropriate code associations (upcoding).

 

Policy Review
Do you experience a high rate of denied prosthetic claims being overturned at the ALJ level? Most often this is due to conflicting and ambiguous coverage verbiage. Forensic Prosthetic & Orthotic Consulting can provide an extensive review of your coverage limitations and exclusions with an eye toward the elimination of ambiguities. Having coverage policies, which are clear and concise are efficient not only for the payer but for the provider and patient alike. With clear coverage policy the case managers and providers know exactly what is required before submitting a claim and can communicate this to the patient before initiating services.

Ensuring patient’s obtain medically necessary services in a timely manner will help your organization meet its patient satisfaction quality measurements in the age of the new ACA.

ACO Development
Is your organization forming Accountable Care Organization collaboratives under the new ACA bill?   DMEPOS items, which include prosthetic and orthotic services, are specifically named under the retrospective bundled payment program and are implied under the prospective bundled payment program.

Forensic Prosthetic & Orthotic Consulting can help you:
  • Identify prosthetic and orthotic service providers who have internal processes to ensure appropriate cost and quality controls are followed and reported.
  • Establish internal prosthetic and orthotic services with your primary care partners existing staff such as hospitals, physician clinics, PT/OT departments, pharmacy, etc.