Discover how pedorthists in Texas can avoid common insurance claims mistakes and protect cash flow with smarter orthotics billing.

As a Pedorthist, you've probably had a patient who has been in pain for months. You study their gait, examine their footwear, review their medical history, design, and fit the right custom orthotics or therapeutic shoes. The patient walks out more comfortable and hopeful. A few weeks later, you open a notice from the insurance company: denied. 

Sometimes the denial makes sense: an obvious typo, a missing form, a mismatch between coverage and what was delivered. But far too often, it feels arbitrary and mysterious. You did good clinical work. You documented everything in your notes. The patient clearly needed the device. So why won’t the payer cooperate? 

Part of the answer is that, in the eyes of insurers, a pedorthist is not just a footcare professional. Pedorthics is formally defined as the management and treatment of conditions of the foot, ankle and lower extremities through fitting, fabricating and adjusting pedorthic devices and footwear. But from a billing perspective, your services fall squarely under the world of DMEPOS (Durable Medical Equipment, Prosthetics, Orthotics and Supplies). That world has its own rules about written orders, medical necessity, proof of delivery, coding and prior authorization, and those rules are enforced aggressively by Medicare, Texas Medicaid and commercial payers. 

The World You’re Actually Billing Into 

To understand why claims go wrong, it helps to picture the rules your practice is judged against. 

On the Medicare side, pedorthic services are treated as DMEPOS. CMS expects suppliers to maintain a proper written order or prescription and all supporting documentation from the treating practitioner, and to make that documentation available on request. The official guidance on DMEPOS order and face-to-face encounter requirements spells this out in detail: the physician’s medical record, not just the supplier’s, must justify the device and show there was a valid encounter. 

On the Medicaid side, Texas uses the Texas Medicaid Provider Procedures Manual, including a long chapter on Durable Medical Equipment and Supplies. That handbook explains when a Home Health DME/Medical Supplies Physician Order Form is needed, what has to be on the form, how long signatures are valid, when prior authorization is required, and how proof of delivery must be documented. It also reminds providers that client eligibility can change monthly and that records must be kept for at least five years. 

Commercial payers; UnitedHealthcare Community Plan in Texas, Superior HealthPlan and others, layer their own policies on top of those federal and state rules. Their manuals and clinical policies for DME and orthotics emphasize the same themes: accurate coding, strong documentation of medical necessity, and timely prior authorization when required. 

So while you are focused on biomechanics and patient comfort, payers are evaluating your claims as if you were a DMEPOS supplier first and a clinician second. Once you accept that reality, the patterns behind those painful denials start to make more sense. 

When Your Documentation Is Strong in the Wrong Place 

One of the most common frustrations we hear from pedorthists is the complaint that their documentation is excellent, so they don’t understand why they are told that there isn’t enough information.  

Often, that statement is half true. Your pedorthic notes might be outstanding. You may carefully document foot deformities, pressure points, range-of-motion findings, and the exact modifications you made to footwear. But Medicare and Texas Medicaid are not just looking at your notes; they are starting from the physician’s record. 

CMS and DME Medicare contractors are very clear that the treating practitioner’s documentation drives medical necessity for DMEPOS items. Suppliers must keep a copy of the written order and the clinical documentation in their files, but they cannot create medical necessity on their own.  

What this means in practice is that your wonderfully detailed assessment can’t rescue a weak referral. If the podiatrist or primary-care doctor writes “orthotics for foot pain” and their note never explains the diagnosis, the functional limits or the failure of simpler interventions, an auditor may decide that the claim doesn’t meet coverage criteria even if everything on your side looks perfect. 

Some pedorthists in Texas have had success creating a short, friendly one-pager for referring physicians that explains what insurers look for when they review orthotics and therapeutic footwear. It might suggest language about gait instability, recurrent ulcer risk, or failed trials of off-the-shelf inserts, in plain English instead of dense policy jargon. Others work with referrers to add a smart phrase in the EHR, so key details are captured every time. Over time, those small changes drastically reduce denials tied to insufficient medical necessity. 

At Delon Health, when we onboard a new pedorthist client, we often help identify the top referring providers and then draft simple documentation guides tailored to their workflow. 

When Coding Is Treated as Close Enough 

Coding is another quiet source of trouble. Many pedorthists see L-codes as labels rather than precise descriptors. Unfortunately, payers don’t share that relaxed attitude. 

Recent discussions of orthotics and DME billing show that wrong or outdated codes, and missing modifiers, are among the most frequent reasons for claims being rejected. One analysis of orthotics billing errors explains that using older L-codes or forgetting necessary modifiers leads directly to denials and longer payment cycles. 

Imagine a patient with bilateral ankle instability who receives a pair of custom AFOs. If the code chosen describes a different style of device, or if laterality is not indicated correctly, the claim may look like an overcharge or a mismatch with the documentation. Similarly, if you keep using codes that were valid three years ago but have since been revised, your staff may find themselves resubmitting the same claims over and over. 

This is not about turning pedorthists into full-time coders. It is about building a small, accurate, regularly updated code map for your practice. That map lists the specific HCPCS L-codes you actually use, describes them in everyday language, notes common modifiers that apply in pedorthic work, and pairs them with the diagnosis types that typically support coverage based on payer policy. Having that map in front of your team means they are not guessing each time, and they are less likely to rely on “whatever we used last year.” 

Our billing team at Delon Health does this kind of translation work constantly. For example, in our article about dental billing software features for multi-location practices, we talk about how built-in coding intelligence and automatic eligibility checks protect revenue across multiple sites. The same principle applies to pedorthics: when your billing partner or software quietly nudges you toward the right codes and modifiers, you simply see fewer denials. 

When Prior Authorization Is Always an Urgent Fire Drill 

Prior authorization is designed to be a gate at the front of the process. In a well-run revenue cycle, the gate opens or closes before any high-cost device is fabricated and delivered. In many real pedorthic practices, however, the gate is halfway down the hallway: staff rush to collect clinical notes and submit forms after casting or even after delivery, because everyone is trying to keep patients moving through the schedule. 

Texas Medicaid’s DME handbook makes it very clear that most DME and many supplies require prior authorization, and that the completed physician order form must be signed, dated and submitted to the TMHP Home Health Prior Authorization Department. Providers are told that prior authorization is usually valid only for a limited period and must be obtained within three business days of providing the service. 

The mistake here is timing. If your clinic treats prior authorization as a last-minute admin chore, it will constantly feel chaotic. If you bring it forward; making it part of the intake and scheduling process for high-risk payers and codes, it becomes boring and predictable, which is exactly what you want. 

A pedorthist in San Antonio once described the turning point this way: “We stopped letting the lab clock drive our workflow and started letting the authorization clock drive it.” In practical terms, that meant patients who needed complex devices were scheduled with enough lead time to complete authorization, staff had a clear list of what documents must be included, and no custom device was ordered until the payer’s rules were satisfied or the practice deliberately accepted the financial risk. 

For some practices, this shift is easier with outside help. A revenue-cycle partner can take over the legwork of assembling authorization packets, tracking decisions, and making sure approvals are correctly linked to claims before submission, so your in-house team can stay focused on patient care. 

When Eligibility Checks Only Scratch the Surface 

Every pedorthist knows the ritual of copying insurance cards and checking whether a plan appears active. Unfortunately, that surface-level check is not enough for high-cost devices. 

Across specialties, revenue-cycle analysts describe the same denial pattern: patients switch plans, lose coverage, or move from commercial insurance into Medicaid or a Medicare Advantage plan. If your team doesn’t catch that change before you fabricate and deliver a device, you may discover after the fact that the claim belongs to a different payer, or that the new plan excludes the service completely. Studies of common claim denial reasons in DME and orthotics billing repeatedly highlight out-of-date coverage information and missing verification as major culprits. 

In Texas, this problem is magnified by the structure of Medicaid and managed care. The DME handbook explicitly reminds providers that client eligibility can change monthly and places the responsibility for verifying that eligibility on the provider before supplies are delivered. If your staff treat eligibility as a one-time check when the patient first becomes a client, you are almost guaranteed to get caught out when their coverage changes. 

A more robust approach feels a little slower at first but pays off in fewer write-offs and fewer awkward conversations. Before you cast for custom orthotics or order therapeutic shoes, someone verifies not only that coverage is active, but that the plan actually covers orthotic devices, what the frequency limits are, whether prior authorization is needed, and what the expected patient responsibility will be. That information is written down in a consistent way and becomes the basis for a transparent financial conversation with the patient. 

Delon Health’s billing team uses standardized eligibility and benefits templates tailored to each specialty. For pedorthists, those templates focus on orthotics, therapeutic footwear, and related DME categories, so verification calls or portal checks capture the details that really matter for your claims. 

When Time Quietly Kills Valid Claims 

One of the hardest things to accept about insurance denials is how many are caused not by medical disputes, but by time. 

Every payer sets its own timely filing limits. Many set separate deadlines for appeals. DMEPOS and orthotics billing experts consistently report that late filing and late appeals are among the top reasons for losing revenue entirely, because once the clock runs out, the payer simply won’t consider the claim, no matter how strong the documentation is. 

The mistake here is not understanding that, from a revenue perspective, a perfectly documented claim submitted two weeks late can be worth zero dollars, while a slightly imperfect claim submitted on time can be corrected and ultimately paid. The solution is to treat billing and denial follow-up as time-sensitive clinical tasks, not as background admin work. 

Some pedorthists resolve this by carving out protected time each day or each week for claim submission and denial management, and by assigning clear responsibility for appeals to a specific person or external partner. Others bring in a billing company like Delon Health, where part of the service is monitoring filing and appeal deadlines and making sure that no claim quietly expires. 

Protecting Revenue in 2025 for Small US Mental Health Practices walks through how small practices can stop revenue leaks caused by delays and disorganization in the revenue cycle. The same logic applies directly to pedorthists: if you control time, you control a huge portion of your collections. 

When You Assume Referring Providers Actually Know What to Do 

Finally, there is the human side of documentation. Most pedorthists work closely with podiatrists, orthopedists, primary-care physicians, endocrinologists and other clinicians. Those colleagues are juggling their own documentation demands. Very few have the time or interest to read every update to Medicare’s DMEPOS requirements or the Texas Medicaid DME handbook. 

The result is that referrals and chart notes are often written the way they have always been written. A diagnosis is mentioned; a general reference to orthotics is made; the expectation is that the supplier will sort out the rest. When claims are later denied for lack of medical necessity, everyone is confused. 

Rather than hoping your referrers will somehow absorb payer policy by osmosis, you can position yourself as a helpful guide. Many pedorthists find that a short, respectful educational conversation goes a long way. When you explain that Medicare’s own DMEPOS standards and the Texas Medicaid manual explicitly require the physician’s documentation to support the device, you are not asking them for a favor; you are helping protect them from audits as well. 

How Delon Health Helps Pedorthists Turn Denials into Reliable Cash Flow 

Avoiding these common claims mistakes is not about perfection; it is about building systems that naturally support good outcomes. 

For pedorthists in Texas, that often means combining three things: clear internal workflows, modest but targeted training for staff and referrers, and the support of a billing partner who truly understands DMEPOS and orthotics. 

Delon Health was built specifically to serve small and mid-sized practices, including pedorthists and other device-heavy specialties. Our services focus on: 

Front-end work like eligibility checks and prior authorization, aligned with the rules in CMS DMEPOS guidance and the Texas Medicaid DME handbook. 

Coding and documentation support that reflects the realities of orthotics and footcare, rather than generic medical billing advice. 

Organized claim submission, denial tracking and appeals, so time stops quietly erasing valid revenue. 

Pedorthics exists to help people move with less pain and more confidence. When your insurance claims process is as thoughtfully designed as your devices, your practice gains the financial stability to keep doing that work without constantly fighting with payers. 

You can read more about our billing philosophy and see how we help other specialties on the Delon Health blog, then imagine the same revenue-protection mindset applied to your pedorthic practice. Visit delonhealth.com to contact us and for more information.