To better understand why we do not accept insurance coverage for custom orthotic insoles, we need to start with an understanding of the word ‘orthotics’. The term is actually a broad term that is used in the orthotics and prosthetics field to mean anything that is used to aid or correct a dysfunctional body part. Just as ‘prosthetics’ is used to mean a device that replaces a body part. Think of the term orthotics as a fancy way of saying ‘brace’. Because of this, orthotics are neck braces, back braces, arm braces, full-leg braces, lower-leg braces, and yes, even custom shoe inserts. All of them are meant to help correct some part of the body with a dysfunction, whether that is from improper alignment or a loss of strength.
Over the years, many shoe insert companies have essentially hijacked the term ‘orthotics’ to make their product sound more professional and provide more brand-trust to their customers. The problem this causes is that when an individual contacts their insurance company and asks if their policy covers custom orthotics, the answer comes back as a resounding ‘yes’. The person then calls the office of a facility that makes them and insists that their insurance covers them, when the reality unfortunately, is that they do not. Or, even if they do ‘cover’ them, they do not disclose all the specific requirements necessary in order to gain that coverage. Most of the time, people do not meet the criteria for coverage. Insurances don’t typically have clear cut answers to generic wording of products when it comes to whether or not they cover them. What an insurance company needs in order to provide the best answer for you is what is known as an L-code. If you were to call your insurance company and ask if they cover custom orthotics, they might tell you that they do, but if you ask them if they cover an L-3020, which is a typical code for a custom insert, they would most likely tell you ‘no’.
The hard truth is that most insurance companies do not cover custom inserts for their customers. And the few that do, don’t pay enough to really keep a business open. Because of this, the list of facilities that even offer custom inserts has dwindled, and of the ones that do, few accept insurance for doing them. The places that do make custom inserts in the area are charging over $400 for a set. And while high, it is not unrealistic when you consider the time and effort they spend, and what they have to cease doing in order to make those inserts. For orthotic and prosthetic facilities, custom inserts are one of, if not, the most basic items they can make. Compare them to making artificial limbs costing $40,000 or more and the resources they have to divert just to make those custom inserts doesn’t make as much financial sense for companies like that. So, they tend to throttle how many they see in a given week or day to make sure they have enough time to work on higher-dollar devices.
Then there is the staffing required to bill insurances. While most facilities have billing staff, they are doing many more items for patients than just inserts, which is why you need the staff to begin with. But since very few insurance companies even cover custom inserts, their talents and efforts are mostly wasted on inserts. At the other facility I worked for, I would often hear conversations between billing staff and patients where the patients would argue that their insurance would cover them and the billing staff would explain why they actually do not and the conversation would drag on for quite some time. Ultimately, probably 95% of the time the insurance did not cover them. Which means all the time on the phone was wasted time. So, because most insurances do not cover them, it made more sense to create a company that could do professional custom-made inserts for people, but do it at the lowest price possible. One of the ways to do that is to have less staff, specifically billing staff. The other way is to streamline the process itself, which we did by really only providing custom inserts (and some ancillary products that support that goal). With focused products, streamlined fabrication and service, and eliminating the need for billing staff, we are able to offer custom orthotic insoles at a lower price than most everyone in the area. Insurance companies, even ones that cover them, make the process much harder and costlier to provide than is feasible to most companies providing custom inserts. For all these reasons, we have made the decision to avoid those complications and simply offer the best service and products we know how, at the most affordable price we can.