¦
Advertisement
Responding to dramatically rising claims for orthotics and related products, some insurance companies have adopted changes, such as limiting the eligible providers who can prescribe and/or dispense these biomechanical devices.
Though other insurers are taking a less controversial "wait and see" approach, all are paying close attention to cost trends.
For example, claims analysis by Great-West Life reveals that, from 1999 to 2004, the average cost for orthotics increased by 9.14%, while the actual number of claims increased 126.86%. In the same period, the average cost for orthopedic shoes increased by 4.42%, while the actual number of claims increased 259.30%.
Jonathan Strauss, executive director of the Pedorthic Association of Canada, cites several reasons for the claims increase.
"People want to stay healthy and active longer. They are also more aware of their benefit plans and what they have to offer." But he also says, "More allied health professionals are keying-in on orthotics and orthotic footwear as a sideline to their main practice and actively promoting their availability to provide orthotics."
Leslie Trotter is both a chiropractor and a pedorthist. She also consults to insurance companies investigating orthotics abuse and fraud.
In a recent presentation to the Canadian Health Care Anti-fraud Association's annual conference, she attributed at least part of the increase in claims to "push-marketing by labs to non foot-care professionals. If you go to one of these seminars, there is as much information about how to market orthotics to your patients as there is hard science as to why people need them."
Trotter also identified several blatant examples of orthotics fraud she has encountered.
"Creative wording of claims can result in the insurance company paying for custom-made orthotics, when the patient actually got a much less costly pre-fabricated product that may have been customized with inexpensive stick-on pads."
Another red flag is bundling of orthotics with "free shoes."
"If someone needs a custom-made shoe because they have an amputated toe or some other condition, that's a $1,200 claim, and it's worth it," Trotter says. "But when employers have orthopedic shoes and customized shoes as part of their bundle, they are just paying for retail shoes for their employees."
But Trotter's major concern is that patients get proper foot care resulting in good medical outcomes. "Patients with a foot problem need to see a foot professional. If a diabetic person wears poorly fitted or fabricated orthotics, an ulcer could develop - and if it becomes infected, he may lose a leg."
Who can diagnose/dispense
In order to ensure patients are treated by qualified professionals, the Pedorthic Association advocates that only family doctors, orthopedic surgeons, sports medicine specialists and podiatrists/chiropodists be permitted to prescribe, while dispensing should be left to pedorthists and podiatrists/chiropodists.
In addition, they suggest that, with the exception of chiropodists or podiatrists, the health professional diagnosing a condition requiring orthotics should not be the same person dispensing them.
"We think there is a potential conflict of interest if some unscrupulous professionals - some, not all - who can prescribe and dispense use their ability to do both to try and drive up their sales volume and increase revenue for their practices. For the same reason, a physician cannot own 100% of a pharmacy," says Strauss.
This message is getting through to the insurance industry - at least in part. Of 11 insurance companies responding to a July 2007 survey conducted by the Pedorthic Association, only three reported that they permit other allied health professionals, such as chiropractors and physiotherapists, to either prescribe or dispense orthotics. Yet 82% of the companies surveyed still permit the same person to both prescribe and dispense.
"This trend toward high utilization of orthotics benefits has happened in recent years, so it's a new problem. It will take [insurance companies] a few years to react," says Sharon Horan, chair of the pedorthic regulator, The College of Pedorthics of Canada.
Other allied health professions
However, the Ontario Chiropractic Association would like insurance companies to lift the restrictions on their members' ability to prescribe and dispense.
"Chiropodists/podiatrists deal only with foot care, while chiropractors deal with the musculoskeletal system as a whole," points out OCA Executive Director Dr. Robert Haig. "As a result, chiropractors are best equipped to do full body assessments - perhaps even more so than family physicians." He also says that studies show back and other problems treated by chiropractors can frequently be improved using orthotics.
While limiting dispensing to foot specialists to control costs may be attractive to insurance companies, Haig maintains there is no clinical basis for doing so. "I've called the College of Chiropractors repeatedly and, to my knowledge, they have never had a claim regarding orthotics, or, if they have, they have been exceedingly rare," he says.
Helen Shwery, a fraud investigator with Equitable Life, agrees with Haig. She says, "Every practitioner group may have one or two bad apples but we do not see any particular group as bad."
If there were regulations as to who could prescribe and dispense orthotics, she says Equitable would comply with them. However, in the absence of such provisions, the company is one of only a few companies that still permits chiropractors to do both.
"At least a foot specialist or a regulated professional is selling or dispensing orthotics," says Shwery. "The real problem is if we get claims for orthotics that have never been sold or employees are getting shoes but we are billed for orthotics."
Even where insurance companies recommend checks and balances, employers may be reluctant to implement them, Trotter says. "Organizations providing benefits want to control costs, but they do not want there to be a sense that the gate keeping is unreasonable."
But Haig believes that Ontario's Regulated Health Professions Act has proved effective in regulating health professionals, and that insurers should consider this when deciding who can provide services.
"If insurers take a stand when regulators of these professions say it is acceptable for their members to provide these services, they lose credibility," he says.
|
Who does what?
*Orthotists and Prosthetists design, construct, and fit artificial limbs and orthopedic devices for patients with body deformities and disorders. * A pedorthist is trained in the assessment, design, manufacture, fit and modification of foot appliances and footwear for the purposes of alleviating painful or debilitating conditions.
* Chiropodists and podiatrists are primary health care providers who are experts in the
management of foot problems.
|
