WHAT’S THE PROBLEM IN THE FOOT ORTHOTIC AND ORTHOPEDIC SHOE INDUSTRY?
Have you ever been offered to choose footwear from a catalogue, told your orthotics are custom made into them and that they would be covered by your insurance plan? If this sounds amazing and too good to be true, it probably is! That’s because it is a hoax by the provider committing insurance fraud and making you a part of this illegal act.
How is this fraud being committed? The bill to your insurance provider is somehow altered or omitted. The provider bills you for something you are not getting or they are inflating the price of products of services you received. Fraudulent providers are very creative in getting the client on board to become a part of the white collar crime. They are experts at making you think this behavior is okay when it is completely unethical in the foot care and insurance industry.
Over the past 10+ years insurance claims for orthotics and shoes are up significantly especially in the last few years. With the increased usage there is the inevitable increase in fraudulent activity. The truth is some seemingly legitimate health care service providers will go to any lengths for profit. They may portray their purpose in life is to help you, but in reality they really want as much money as they can from your insurance company. Today orthotic claims that are potentially fraudulent are an easy way for providers to make large sums of money with little effort. These schemes can often involve selling you something that is not an actual custom-made orthotic, or the submission of altered of falsified insurance forms. Obviously, that it is not a legitimate custom-made orthotics claim.
WHY ARE WE EXPOSING THE FRAUDULANT PRACTICE IN THE FOOT CARE INDUSTRY?
We take your insurance coverage as a privilege. Why? Because third party insurance plays a large part in people's accessibility to our Chiropody service. Without insurance coverage our paycheque would be in serious jeopardy. The majority of people would not be able to afford our services. As a result, most people would tolerate discomfort or pain before getting their condition treated. This is why we are providing an important public service announcement to any person looking to replace or acquire new custom made orthotics. The goal is for you to keep your existing coverage so we can keep our jobs. Many health care providers have been investigated and delisted from insurance companies for not following the rules. As a result, they have lost their privilege to have their billing number used for product or service reimbursement from the insurance company.
THEY HAVE BEEN BLACK LISTED. However, they continue to have a professional licence within their regulated health college.
Some may ask themselves why is the insurance industry policing a regulated health professions. Or why is the insurance industry making the decision what is covered in a benefit plan? Well that is easy, an insurance company is a business and a regulated health profession or college is there to protect the public from harmful acts from a registered provider. The rules of coverage are an INSURANCE POLICY and was created by the insurance company (IT'S A BUSINESS). Employers or employee pay partly or in full the policy dues (THESE ARE THE CONSUMERS). Regardless the POLICIES were agreed upon between two parties when signing up for the insurance policy. The employee must follow the rules and the health providers have a liscence to provide ethical services. The few who do not follow the rules make the rest of us pay higher deductibles and fees.
WE ALL PAY THE PRICE IN THE END. Or the service is taken away from all of us.
INSURANCE COMPANIES ARE FEELING THE PRESSURE.
When claims increase profits go down. Thus, auditing claims are increasing, payment reimbursements are slowed down, claims are denied or even the elimination of the shoes and/or orthotics Group Plan coverage. Cost cutting measures to legitimate clients who deserve their reimbursement are occurring because of a few individuals playing the system.
Now you may be thinking, “This does not apply to me because”:
• My orthotic provider is well known and respected.
• He or She has an up to date license with no investigations at the College level.
• They always accommodate me with certain billing requests or offer to alter billing so I can get my money back.
• They are simply “Nice People” and they would never put my coverage at risk!
WHAT DO THE CURRENT FAUDULENT ACTIVITIES LOOK LIKE?
1- FREE SHOES (footwear products – such as off the shelf running shoes or dress shoes) Usually, the shoes never show up on the paperwork because the cost of the shoes are hidden in the orthotic paperwork. How would this be covered? The provider increases the cost of the orthotic to cover the cost of the footwear. If you look at the paperwork you are submitting to the insurance company- no footwear information would be found.
There are no such things as free shoes.
HOW DO YOU PROTECT YOURSELF AND HELP US PREVENT FRAUD?
Here are some tips that may help reduce the chances of fraud – and ensure you don’t end up being involved in a suspected fraud scheme unintentionally.
Never sign a blank claim form, or give a service provider personal information such as access IDs or passwords that would allow them to view your claims history and update your personal information such as address and bank account.
Do not accept offers from service providers, such as receipts for anything other than what you received (for example, providers selling you running shoes while providing a receipt for orthotics). It is also important that you keep your receipts for one year. Sunlife may request additional information from you regarding the services or products you received. Please respond to these requests so we can ensure the payment of your claim is correct.
Don’t buy orthotics from service providers who offer free merchandise or two-for-one deals with the purchase of a product that is covered under your benefits plan. Beware of these types of offers as this may be a sign that the provider does not have your best interests in mind. He or she may try to give you something you don’t really need or it will make you reach your maximum coverage so you may not be covered for another item that you really need. You should also question suppliers who recommend extra pairs of orthotics just because your benefit plan pays for them.
Avoid purchasing orthotics from temporary locations, such as a private residence (BASEMENTS) or trade show exhibits, kiosks or health booths in malls or department stores – or through mass screenings at work or home: where the service providers offer orthotics to entire families or groups of people without properly evaluating each person.
Do not purchase orthotics online. A proper assessment of your medical need for orthotics cannot be performed online. If purchases are not qualified under your benefits plan, then you are responsible for the cost of any such purchases. And, please remember, if a deal seems too good to be true, it probably is! Don’t hesitate to question the treatment or service being prescribed or given to you. If you are unsure, do not be afraid to seek a second opinion.
If you are involved in fraudulent activity. Stop it!
If you know of a provider that is involved in fraudulent activity report them to their respective college complaints committee. Healthcare anti-fraud is also available to report suspected fraudulent activity.
DO YOUR PART IN KEEPING THE SYSTEM FRAUD FREE.
Here are some references and links to help you:
1- Canadian Life and Health Insurance Association ( Understanding Footwear and Orthotic Claims )
Note: Patients whose condition(s) can be accommodated by orthotics are generally not also eligible for coverage for custom made or orthopedic footwear. Pg. 6 of the reference document.
2- Sunlife orthotic and shoe article:
OCTOBER 2012 Life’s brighter under the sun Group Benefits are offered by Sun Life Assurance Company of Canada, a member of the Sun Life Financial group of companies. PDF5800-E 10-12 clm-rn * Canadian Health Care Anti-Fraud Association website: www.chcaa.org, 2012
A special thank-you to Rainville Health for creation and sharing of this education document.
THERE IS NO SUCH THING AS FREE SHOES
So how are you or someone you know getting
FREE SHOES PAID FOR BY YOUR INSURANCE PLAN?
You may knowingly or unknowingly be participating in insurance fraud.
This document is intended to educate and prevent future fraud.