You may knowingly or unknowingly be participating in insurance fraud. This document is intended to educate and prevent future fraud.
Why Are We Exposing The Fraudulent Practice In Our Industry:
At Step By Step we take your insurance coverage as a privilege. Why? Because third party insurance plays a large part in why people access our Chiropody service. Without insurance coverage fewer patients would be able to receive the care they need, and our paycheck would be in serious jeopardy. 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 and provide as many patients as possible with appropriate care.
What’s The Problem In The Orthotic / Orthodepic Show Industry?
Claims of orthotics and shoes are up in the last few years since we entered the foot industry over 20 years ago. So with increased usage fraudulent activity will inevitably also increase. The truth is some seemingly legitimate health care service providers will go to any lengths for money. They may portray their purpose in life is to help you, but in reality they 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 and low quality products. These schemes can often involve selling you something that is not an actual custom-made orthotic, or altering / falsifying insurance forms submitted so that it is not a legitimate custom-made orthotics claim.
Insurance Companies Are Cracking Down
When claims increase profits go down. Thus insurance companies are auditing claims more frequently, payment reimbursements are slowed, more claims are denied – some insurers are even eliminating shoes or orthotics from Group Plan coverage. Cost cutting measures hurt legitimate clients who deserve their reimbursement, all because a few greedy individuals are abusing the system.
Now you may be thinking, “This does not apply to me because”:
- My orthotic provider is well known and respected.
- He/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 Fraudulent Activities Look Like?
FREE SHOES / footwear products (such as off the shelf running shoes or dress shoes, often at an inflated sticker price) – 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 inflates the cost of the orthotic to cover the cost of the footwear. Check your paperwork before submitting to the insurance company; if no footwear information is shown, this is a fraudulent claim. 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.
- Personal information: 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.
- Receipts: 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. Insurance companies 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.
- Special deals: 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.
- Assessment: Avoid purchasing orthotics from temporary locations, such as a home or trade show exhibit, 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.
- Online: Don’t purchase orthotics online, as a proper assessment of your medical need for orthotics cannot be performed. 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, don’t be afraid to seek a second opinion.
Here are some references and links to help you:
- Canadian Life and Health Insurance Association ( Understanding Footwear and Orthotic Claims )
html/clhia/clhia_lp4w_lnd_ webstation.nsf/resources/ Guidelines/$file/Ref_Doc_ Understanding_claims_for_ footwear_and_orthotics_E.pdf
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.
- Sunlife orthotic and shoe article:
static/canada/Sponsor/About% 20Group%20Benefits/Group% 20benefits%20products%20and% 20services/Fraud%20Management/ files/Fraud%20Topic% 20Orthotics%20Final%20ENGLISH.
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