Let me start by saying for good or bad, insurance rules the world!

In my first blog (before the pandemic) I addressed insurance language and what it means.

Why is a fracture considered a surgery/procedure?  The short answer is your insurance company has decided it is a surgery/procedure.

How does this affect me?  The Doctor, Nurse Practitioner or Physician Assistant will assess the injury or fracture and determine what needs to be done next.  This could be casting, bracing, physical therapy or a combination.  This assessment is an office visit and an office visit copay applies. Diagnostic x-rays are NOT included in the copay and go towards your insurance deductible.  The fracture care which is considered surgery/procedure goes toward your deductible.  If x-rays are done at an imaging facility or hospital, those services will go towards your deductible along with a radiologist service. The insurance rules remain the same no matter where services are rendered.

If your child has a fracture, “fracture care” CPT code is submitted to your insurance and will be applied to your deductible.  This package includes the first cast or splint application (excluding casting supplies) and 90 days of uncomplicated follow-up care.  Items not included in the fracture care CPT after your initial visit: x-rays, all casting supplies, any REPLACEMENT cast or application of cast/splint, evaluation/ management of any additional, separate or new problems including injuries, vitamin D management and other complications.

Why does your office collect a portion of my deductible at time of service?  At the time of the office visit, our office has contacted your insurance company to determine if you have met your deductible.  If the deductible is not met, we will collect a portion of your deductible. Our office has determined an average reimbursement from insurance companies for this fracture care code and will collect that amount.

What happens at the follow up appointment? Cast/splint usually is taken off to assess the skin prior to x-rays.   X-rays will be ordered to determine the healing of the bone or injury.  As stated above, x-rays are not included in the fracture care code. If another cast or splint is applied, this also is not included in the fracture care code.

Will my insurance be billed for the services?  All charges will be submitted to your insurance.

Will I receive any additional bills? Your insurance determines what will be paid, what goes toward your deductible, what POSA writes off (contracted rates) and what you owe.  We will send out a bill if the insurance company has determined you are responsible for any additional amount.

Once again insurance companies rule the world!

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Up next: The importance of follow-up care after a fracture