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As previously stated, the use of KX modifier should only be used if the policy states:
1) Foot orthotics are covered for …. diagnosis and the patient has that diagnosis, AND
2) There is no mention in the policy that they follow Medicare guidelines for DME coverage (or something like that), OR
3) There is no stipulation that the orthotics are only covered if placed into a shoe that is an integral part of a brace.
Numbers 2 and 3 are currently the center of recoupments for Anthem and other carriers. The last thing you want is to join this party and be accused of misinterpretation of the policy. In the Anthem and other cases, the national policy of the carrier may either state they are “following Medicare guidelines”—being interpreted as meaning foot orthotics are only covered when the orthotic is placed into a shoe that is an integral part of a brace. However, the local policy may usurp that, so be sure the carrier is following the correct policy.
As for your situation, if this is a system-wide issue affecting other foot orthotics in Texas, these are the steps I would take:
Ask your patients who their group plan administrator is and contact them. If they don’t know, contact the company’s human resources (HR) department. My dad was an HR executive, and his group plan managers always could cut through a great deal of red tape for their employees that you cannot. When in practice, using this enabled me to frequently get answers in an amazingly short time.
In addition:
1) Tell your patients that you can no longer provider certain services because the insurance company refuses to abide by their contract. This will undoubtedly upset some, but most patients understand the pressures of modern-day practice. Their communication to their HR department will undoubtedly result in some action on the part of the insurance carrier.
2) Even if you are not an APMA member, contact your APMA private insurance company rep (PIAC). If this happens to you, it no doubt is happening to others in your state. In November the CAC/PIAC meets in Washington DC, and I will report this to them. The most recent contact I have is Leslie Campbell, who is also an APMA BOT member.
3) Enlist the assistance of the Texas attorney general’s office. Doing a bit of research, it appears that this office has the power to investigate insurance companies for fraud and abuse, as they did with Molina, UHC, BC, and others over denials and delays of medically necessary care. See https://www.texasattorneygeneral.gov/news/releases/attorney-general-paxton-investigates-blue-cross-blue-shield-insurance-company-over-denials
4) The Texas insurance department will also investigate complaints against insurance companies. See https://www.tdi.texas.gov/fraud/index.html
While in practice in New York, these were commonly used tactics to get insurance carriers to pay. Always try 1, 2, and 3 first. If that fails, the big guns of 4 and 5 will no doubt get some results. The last thing a carrier wants is the attorney general or state insurance department breathing down their necks. In all cases, let those you are reporting this to know that Blue Cross is violating their contracts with you, as well as committing HIPAA violations. This because they are not following accepted billing guideline sets.
Good luck and let us know what happens.
—Paul Kesselman, DPM