OK to reimburse?

[SLuskin]

A participant has submitted a claim for a Tempur-pedic pillow. He has numerous visits to a spine center. There is no other info in the file. I know that every chiropractic office sells them, and that you can also order them on tv. No prescription is required. Would you reimburse this expense? Thanks.

[maverick]

I used to work for an insurance company that specialized in group products (like flexible spending accounts). We would deny a flex claim if the pillow was purchased over the counter/via tv. However, if the chiro gave the pillow (like an orthopod giving someone a knee brace) to the patient, then ran a claim through the group insurance policy (which would deny the charge), a participant could then submit a flex claim. It worked for me with one of those cushions/supports that goes between your spine and the chair back.

Maverick

[mroberts]

I tend to agree with maverick. If the pillow came from the chiropractor's office and the doctor has certified the need for it, I would reimburse the employee.

If the employee went to the store and picked it up or ordered it off of TV, then that's a different story.

[Jbentz]

In the case you gave, i agree with maverick and mroberts with the exception being if the claim was accompanied by a script from a provider, even if it was off the tv or a drugstore. My reasoning is that if he can find the exact same item cheaper and it is at his own expense, he should have the freedom to purchase it where he wants to.

[SLuskin]

So, you all agree that we need to have the participant go back and get us a diagnosis from the chiropractor - just the fact that we have alot of copays for "manipulation" from that same office isn't enough?

I guess my problem is that, in our area, at least, chiropractors (and dentists) have started selling alot of products to supplement lost income from managed care situations. My adult sons both go to chirpractors for "tune ups" and they are always being told to buy stuff.