A red flag goes up for Dan Mead whenever an orthotics customer comes into his clinic asking about getting free shoes.

“Clearly, we do see the issue, because patients do come in to our office, just speaking anecdotally . . . and you can tell what they’re looking for,” says Mead, a certified prosthetist and orthotist in Sudbury, Ont., and president of Orthotics Prosthetics Canada.

“And if they don’t have any issues with their feet, it’s sort of an awkward silence where you’re sort of like, ‘Well, I don’t understand. You’re not having any problems with your feet. You don’t need foot orthotics,’” says Mead.

Incentives, such as getting free shoes alongside an unnecessary claim for orthotics, are a growing concern for people like Mead. Often, he says, the shoes are a pair selected from a catalogue that will work with an orthotic device but without much difference between a product offered as an incentive and something a customer would normally pay for. And as one pedorthist suggests, it’s not necessarily difficult for plan members to find someone willing to provide a prescription.

Jonathan Strauss, chief executive officer of the Pedorthic Association of Canada, says he’s aware of providers offering incentives ranging from steering wheel covers to luggage and handbags to plan members.

Have your say: Are orthotics claims a concern for benefits plans?

When providers offer incentives, word tends to spread in workplaces, says Mead, referring to situations “where one person finds out that there’s an incentive and then they start talking about it at work and everybody goes in that direction to obtain it.”

Orthotics Prosthetics Canada, a national organization for the prosthetic and orthotic profession, doesn’t permit incentives, according to Mead. Insurers should only accept claims from designated providers, he suggests.

“You need to go to a professional that has a regulatory college where there is some form of discipline that is lasting and meaningful. Some of the colleges, their discipline is a fine. There’s no . . . sanction of a potential loss of your certification. Ours has teeth. There have been providers that have lost their certification. It doesn’t happen often, because people generally are abiding by not only their colleges’ regulations but they have contracts with the Ministry of Health.”

Strauss says his organization also has a policy in place for its members, but he notes the issue of incentives isn’t an easy one for insurers to deal with. He believes insurers need to limit their lists of qualified dispensers of custom-made orthotics.

“The challenge is that the vast majority of insurance plans today are concerned with who the prescriber is, not who the dispenser is. We feel that the health-care professional that puts the orthotic in the shoes, being the final step in the process, is who needs to be held accountable,” says Strauss.

Read: A free purse with a benefits claim? How incentives can land providers, employees in trouble

“If insurance companies want to reduce fraud and abuse, then they would consider ways to control who’s actually dispensing the products.”

He refers to a couple of payers, including Health Canada’s non-insured health benefits program, that have a list of dispensers and a separate one for prescribers. “And that’s how you can look at reducing fraud and abuse . . . [by] controlling who can dispense the product.”

Those offering incentives are often what Mead calls non-certified sources. He gives the example of a business referring to staff who don’t have a designation as trained foot professionals.

Strauss also notes the importance of reimbursing only custom-made products rather than cheaper off-the shelf variations through so-called library matching. “It’s premade, but typically library-matched come in a very large variety of widths, shapes and sizes,” he says.

“There are labs, many of them who do library matching, that will teach you how to invoice an insurance company in order to get paid for foot orthotics even when you’re not qualified to dispense them,” he adds.

Read: Insurers stepping up fight against benefits fraud with analytics, big data

Strauss acknowledges, however, that it can be difficult to distinguish a library-matched orthotic from a custom-made device. “That’s the challenge. It’s not always obvious. It’s not like you and I could take a lineup and say those are library-matched, those are custom-made. It’s not quite that simple,” he says.

On the other side of the issue, proponents of library-matched products note many orthotic devices come in recognizable and predictable shapes. A 2015 article in Lower Extremity Review, for example, quoted a laboratory owner who compared such products to eyeglasses produced in an hour and called for rethinking the definition of what a custom orthotic is.

The issue of incentives is on the radar of insurance companies. In its case, Sun Life Financial Inc. maintains a list of providers and facilities it has delisted, according to Shelley Frohlich, director of the insurer’s investigative services unit. There’s no government regulation of who can dispense certain medical equipment like orthotics, she notes.

“I would agree that an insurance carrier has to conduct a certain level of review and/or investigations into the claiming patterns of various providers and facilities for various reasons. One of the things that we do is, after a review is conducted or an investigation is conducted and if we have information that warrants a delist, we put through a recommendation to delist a provider or facility so that we’re no longer allowing claims to be reimbursed when the services or products are provided by either that provider or that medical clinic or facility.”

The abuse of benefits, such as accepting incentives when claiming unnecessary products, threatens the sustainability of group benefit plans, she adds.

Read: Manager in Sudbury benefits fraud case ordered to pay $20M to former employer

“The concern isn’t the claimant using their benefits when they or their family members have a medical condition that warrants the service or product, but really the concern is that some providers and vendors promote inappropriate incentives to entice customers to purchase medical products and services that may not be medically necessary,” she says.

“And if it wasn’t for the free item, the claimant would not otherwise have made a claim. This type of abusive claiming activity really jeopardizes the sustainability of benefit plans and really hurts those who do need the services or products the most.”

Frohlich suggests it would be helpful to have some government regulation of the dispensing of medical equipment, especially given the risk of harm from an incorrect product.

“I think insurance carriers, too, need to have some kind of a review process to ensure that the providers and facilities that they’re allowing claims to be paid to are providing the proper services,” says Frohlich.

“And I’m not just talking about incentives, either, but really when we’re talking about fraud and abuse, you need some kind of a review process.”

Read: ‘Sigh of relief’ as university professor’s firing for benefits fraud upheld

When it comes to orthotics, they can be significant component of a plan sponsor’s overall health-care costs, says Adrianna Stuart-Hagge, an associate vice-president at Toronto-based Accompass Inc.

“Certainly not as large as drugs and things like that, but foot orthotics can certainly fall out of line very quickly in an organization and their benefits plan and certainly would drive up cost,” she says.

Stuart-Hagge notes providers sometimes offer incentives to get people in the door and make money from the activity on a volume basis. There are a range of approaches, she points out.

“In some cases, there are all kinds of different frauds and scams out there, where . . . they provide a receipt but don’t actually provide the orthotic or they charge 10 times the amount of what the orthotic actually cost the clinic . . .. And then there’s money for other items like purses and high-heeled shoes and all kinds of other things,” she says.

Given the concerns, are orthotics claims are a concern when it comes to the sustainability of benefits plans or are they a minor issue when compared to the cost trends in other areas, such as prescription drugs. Have your say in Benefits Canada‘s online poll.

Read: TTC fraud update: More than 220 employees fired or have resigned, retired

Last week’s poll question asked about the findings by the Sanofi Canada health-care survey on wellness program offerings. The majority of respondents (56 per cent) felt the declining number of plan sponsors offering wellness programs is a concern but suggested it’s more important for employers to look at what’s effective rather than making investments without clear objectives. Another 28 per cent felt workforce demographics and health trends point to a need to invest in wellness, while 16 per cent said the findings weren’t a concern as workplace culture matters much more to employee well-being.

Copyright © 2019 Transcontinental Media G.P. Originally published on benefitscanada.com

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Keith:

Working in this field it is difficult as different regulatory/governing bodies seem to enforce and police incentives differently.

It is difficult as a clinician to be strictly bound your regulatory/governing agencies policies, while members of a similar profession offering similar services along with incentives can operate with minimal repercussions or oversight. It makes it very challenging to own a business and nearly impossible to compete with these individuals.

Governing bodies then discipline their own members when they may only be trying to compete in the market instead of advocating for their members against other “colleges” who allow or are much more “lenient” with the enforcement of incentives.

Its a complicated issue with many layers unfortunately.

Tuesday, July 03 at 10:52 am | Reply

David Kerbl, DCh:

As long as health insurers use physicians as claim gatekeepers there will be tremendous abuse and fraud. It is irrelevant that a person receives an orthosis from a dispenser when the dispenser is provided a prescription, it is their role to fill it. Limiting prescribing to foot specialists ie Podiatry and Chiropody means that there will be minimal inappropriate prescriptions. As long as orthoses are considered by insurers as medical devices and not a treatment modality of a foot specialist there will be no reduction in fraud or abuse. Businesses should not be dispensing orthoses. Orthotic treatment should be managed by regulated foot care professionals

Tuesday, July 03 at 1:10 pm | Reply

Andrew Longbottom:

There is no doubt library system orthotics coupled with incentives lead to an over utilization of benefits. The plan holders (the employers) are the ones that end up paying the increased yearly premiums. They need to request that the insurers have policies in place to prevent this kind of abuse. The role of the colleges is to protect the public by governing its members – all colleges should have similar policies in place. Together this will help make a level playing field for all clinicians.

Tuesday, July 03 at 1:37 pm | Reply

Steve Humphrey:

So this is why it is so hard to get legitimate need of orthotics covered by benefit companies. You have a real need and have to fight for months to get the reimbursement that is supposed to be covered by the plan.

Wednesday, July 04 at 5:03 pm | Reply

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