Most insurance programs, including Medicare, provide coverage for reconstructive prosthetic devices. Every prosthesis we fabricate is reconstructive not cosmetic based on definitions given by the American Medical Association which state:
Reconstructive surgery refers to surgery performed on abnormal structures caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease. This can include surgery to improve function or to give a normal appearance. Cosmetic surgery is the reshaping of normal structures on the body to improve the self-esteem or appearance of a patient.
Physician’s orders and clinical notes that include detailed information about the medical necessity of a prosthesis are needed for prior authorization and claim submission. We are patient advocates and take an active role in educating insurance companies about the needs of our patients and helping patients maximize their benefits. Our office routinely submits pre-determination of benefits and insurance claims for our patients. Patients may be asked to assign benefits directly to our office and pay any deductible or co-payments upon completion of the prosthesis. In cases of hardship, payment plans can be arranged. MasterCard and Visa are accepted.
We are currently participating providers with several insurance networks. If we are not a participating provider with your insurance network we can often negotiate a single case agreement or geographic gap exception with your insurance provider when your physician is referring you to our office and network inadequacy can be established.
Medical Art Resources–Milwaukee is a Medicare provider. If you are part of a Medicare Advantage plan we will prior authorize with your insurance network.
We are enrolled as a Medicaid provider in Wisconsin, Indiana and Arizona.
We work with veterans through William S. Middleton Memorial Veterans Hospital in Madison, Wisconsin and Clement J. Zablocki Veterans Affairs Medical Center in Milwaukee, Wisconsin. Referrals from other veterans’ facilities can also be arranged.
Workers Compensation Insurance
When traumatic injury occurs during work, your reconstructive prosthesis is usually covered through worker compensation insurance. Your nurse case manager can help facilitate an authorization and coordinate your initial consultation.