For insurance pre-authorization, we first comb through your insurance policy to get an idea for what types of prosthesis will be covered. We then openly discuss any and all potential costs with our clients to ensure expectations are aligned and to eliminate any future surprises in billing. From there, we reach out to your insurance provider to discuss coverage options, working on your behalf to build a case for coverage if it’s not available currently.
It is pretty common that an initial insurance coverage assessment reveals there is no coverage. But, MCOP’s insurance and billing team works diligently with the insurer to compile documentation for, and obtain, a one-off exception that would provide coverage for your prosthetic or orthotic system.
Device type coverage specifics is different with each insurance provider, but we find that devices that have been on the market longer are more likely to be covered by insurers.
Yes! If your device was provided by MCOP and covered by insurance, then all maintenance and components of your prosthetic system are also covered.
Yes, Medicare does cover prosthetics. As well, other insurance providers often benchmark Medicare prosthetic standards for their own policies and plan offerings.
Yes, Medicaid also covers prosthetics.
When your prosthetic device is designed by MCOP Prosthetists, all of the necessary components and related appointments are normally covered, including fitting and therapy sessions. Future device maintenance is also covered.
You should bring your prescription from your Doctor, insurance information, and X-rays (if available). If you already have prosthesis/orthosis be sure to bring it along even if it is broken or you have outgrown it. It is also a good idea to have a family member or close friend accompany you. They will help you remember conversations, instructions, and will most likely ask questions you may not have thought to ask.
You will need to wear or bring appropriate clothing to your appointment. If you are being seen for: Lower limb brace or lower limb prosthesis wear, bring shorts. Also, bring the shoes you plan to wear with the device. You are welcome to bring multiple. For appointments regarding spinal/back brace, upper limb brace, or upper-limb prosthesis, wear or bring a tight-fitting t-shirt.
You will be shown to a patient room specific to your needs and one of our practitioners will begin their initial, comprehensive evaluation. You will be asked questions about the nature of your condition and probing questions about your lifestyle, interests, and levels of activity. The more we know about you and how you live, work, and play, the more effective we will be in successfully creating a device appropriate to your needs. We will discuss your options.
Depending on your situation the practitioner may measure or take a custom impression for your prosthetic or orthotic device.
As you leave you will be asked to make a return appointment for the actual fitting of your prosthetic or orthotic device.
An orthosis is a device applied on the exterior of the body to limit or assist motion or reduce the load on a part of the body. Any disorder that results in a muscle or ligament imbalance may cause physical or structural deformity in a body part or specific joint. Abnormalities are sometimes the result of neurological problems, genetic disorders or trauma. Many disorders in children can be treated with orthoses, sometimes referred to as braces. The specific device used will be determined by the child’s physician, physical therapist, orthotist, and/or occupational therapist.
An orthosis works just as braces on teeth work, by applying pressure to the structure of the body part(s) and joint(s) of concern. What makes external bracing more complex is the need to apply this pressure through the skin and its underlying tissue. The need to minimize the skin and tissue injury as a result of this pressure requires an extremely accurate fit of the brace to the child and regular adjustments. Just as is the case for braces for teeth, adjustment of the orthosis as the child grows is an important part of the treatment. When adjustments can no longer be made, the orthosis must be replaced.
A medical diagnosis is always the first step. An orthotic evaluation is the second step, and the treatment process continues with the impression, fabrication, fitting and the follow-up.
Orthotics is taught at the college and masters levels, with an additional internship and an examination by the American -Board for Certification in Orthotics and Prosthetics (the ABC) required before an individual is recognized by the ABC as a certified orthotist. Orthotists are trained to fabricate, fit and maintain orthoses. They are experienced in examining deformity and estimating potential correction.
Evaluation is an ongoing part of treatment at OPC. It allows us to know when modifications or adjustments are needed and when it is time for replacement. In addition, the child’s size, physical condition, secondary pathologies, cognitive abilities, age and family situation all play an important part in the design of each brace.
Fabrication of orthoses, or orthotic devices, starts with making an impression of the limb. From this negative mold, a positive plaster model of the limb is made and modified. The more accurate this impression is, the easier the laboratory procedures will be.
The fabrication of the orthosis can be started when modifications are completed. Depending on the type of orthosis prescribed, the proper thermoplastic material, carbon fiber, or metal is selected and cut to the correct dimensions for forming. The type and thickness of the material used is based on the requirements of the individual child.
When a thermoplastic material is chosen, it is heated in an oven until it reaches its liquid state. At this time it is stretched over the model and sealed, and vacuum is applied. Vacuum is maintained until the plastic has set. After this initial set takes place, the orthosis must remain undisturbed for 24 hours to allow the stresses in the plastic to normalize (anneal). The orthosis is then trimmed out, the edges of the orthosis are shaped to allow the brace to fit comfortably inside a child’s shoe or sneaker (when necessary), and then they are finished by sanding and buffing to achieve a smooth edge.
Once the orthosis is finished, the velcro or lace strapping system is designed, fabricated and attached. At this point the orthosis is ready for fitting to the child.
While orthoses look similar, each is highly individualized because of the modifications necessary to apply the precise corrective pressures each child requires.
Correcting the positions of the various parts of a body joint is a complex undertaking. Because it is difficult to obtain a perfect impression from children, and because there can be day-to-day changes in tone, OPC orthotists expect to adjust the orthosis to accommodate small, but important, differences between the time the impression is taken and the time of application.
A follow-up is scheduled, on an individual basis, and the amount of subsequent care required varies widely. At the very least, your child will need to be seen three times. The normal spacing of these visits is once two weeks after delivery, and twice at three month intervals. Any special requirements your child has may change this schedule.
The laboratory time required to design and produce a custom orthosis varies with the complexity of the case. If each step goes smoothly, an orthosis requires a minimum of seven hours laboratory time and two hours of direct patient time. Patients at OPC are scheduled so that laboratory time directly follows the time scheduled for taking the impression. If this time is not interrupted by emergencies, the fitting appointment follows in one to two weeks. Your child will receive an appointment for the fitting at the time of molding and casting.
Costs are a major concern for parents. To satisfy the requirements of the insurance companies that cover children’s orthotic treatment, OPC bills all services as a single device charge. This means that initial evaluation, the plaster cast impression, the laboratory time to make the device, the fitting of the brace and follow-up visits are billed to the insurance carrier at one time.
Orthoses known as AFOs (Ankle Foot Orthoses), help to manage foot and ankle positioning in children with cerebral palsy, spina bifida, muscular dystrophy and other neurological or genetic disorders. AFOs hold the ankle in a stable position and provide a stable base of support for the lower extremities, enabling the physical or occupational therapist to facilitate improved mobility at the pelvis and trunk. AFOs, by providing a stable position for the foot and ankle, allow the child to concentrate more on the physical process of walking and less on balancing. In children with cerebral palsy, AFOs are often prescribed when a child can achieve the correct foot position during therapy, but is unable to maintain it later. AFOs also may be appropriate to prevent foot deformities, even for children who do not walk.
When your child is fitted with an orthosis, you will receive written wearing instructions. Some of the points included in the instructions are: