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Dynamic Chiropractic Canada – November 1, 2013, Vol. 06, Issue 11
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Are Economics Influencing Your Clinical Recommendations?

By Lori Yarrow, DC

Exactly when did we allow a patient's insurance plan or dispensable income dictate our clinical recommendations? Was it around 2008, when the economic purse strings started to tighten, or even earlier? If you used to recommend custom orthotics as a regular part of your practice, but slowed down or stopped altogether, you are not alone.

Maybe your patients lost their insurance or maybe you were tired of feeling like a "used car salesman" – trying to convince them to invest in their feet when the pain was in their back.

After a while, it becomes a grind; as a result, many chiropractors have let this aspect of their practice slip away and are only gradually reconsidering the value of helping their patients heal from the ground up. However, if the bottom line for not offering custom orthotics is economic in nature, there is a way to get a win-win for both you and your patient, whether you take insurance or run a cash practice.

Consider this scenario: Your patient has been seeing you for a number of years and presents with plantar fasciitis. You try many techniques and modalities to control the inflammation, but the underlying cause is that they are overweight; therefore, the plantar fasciitis never resolves.

Custom Orthotics - Copyright – Stock Photo / Register Mark Being the good doctor you are, you coach your patient on good nutritional habits, stretching and regular activity; but this is where you hit a crossroad. They can't exercise with pain in their foot; in fact, they have also started having pain in their knee. What is your next clinical decision – would a custom orthotic help?

Most chiropractors would agree that a custom orthotic would help this patient, yet find themselves not making the recommendation for one of the reasons mentioned above:

  • You don't offer orthotics anymore.
  • You don't think your patient can afford them.
  • You don't know the codes to get successful reimbursement.

Let's start with the first reason first. If you don't offer orthotics anymore, it's time to get back in the habit. The population is getting older and obesity continues to be a problem. Even if you have a wellness or family practice, you can't avoid these demographics and the foot problems that come with them. Don't deny your patients the chance to get better.

In addition, as an expert in the closed kinetic chain, you understand that the gait of your patient directly impacts the function of their spine. If you feel like you need a refresher, look into a webinar that will refresh your knowledge on assessment and casting, as well as the technology now available.

If affordability or the perception of affordability is the only obstruction to your patient's relief from pain, you have two options available. You can allow them to pay for the custom orthotic over three to four payments (I recommend no more than four payments), doing this through postdated checks or a credit card on file. You can also have them do a trial with a quality, pre-fabricated orthotic and see if it gives them relief. This trial-and-error approach is a great way for your patient to educate themselves about the value of a custom orthotic and that the investment is worth every penny.

The final reason many chiropractors have stopped offering custom orthotics is the administrative tasks and knowledge required to successfully collect insurance. Solo practitioners are even less inclined than chiropractors who practice in multidisciplinary clinics with designated insurance administrators.

Successful insurance billing is a process that begins with your examination, diagnosis and creation of a treatment plan. Once you have established the medical necessity for a customized orthotic, the next step is to determine whether your patient's insurance will cover the devices. The insurance company will not disclose the plan details to you or your staff unless the patient is with you and gives the agent verbal permission to do so. Another option is to provide your patient with a list of questions to ask their plan administrator or look up online. Questions they should ask include:

  • Can a chiropractor prescribe a custom orthotic? Can they dispense a custom orthotic?
  • Is a 3-D volumetric cast (foam or plaster) required or do they accept other casting methods (e.g., 2-D pressure scans)?

A "prescriber" is the person who writes a note that must include the patient's diagnosis (e.g., plantar fasciitis) and treatment (custom orthotic). Your patient may need to visit their family doctor for this prescription. The "dispenser" is the person who completes the biomechanical exam and gait analysis, casts the patient, writes the orthotic prescription (posting, additions / modifications), sends the cast to the manufacturer, receives the orthotic, pays the manufacturer, fits the orthotic in the patient's shoe and receives payment from the patient.

As a chiropractor, you may be the "prescriber" and the "dispenser" – check the patient's insurance plan before you order the custom orthotic to prevent claim denial. The "dispenser" should provide the patient with the following paperwork when the patient picks up the custom orthotic, considered the "dispensing date":

  • Proof of manufacturing, which includes the patient's name, casting method, raw materials used to make the custom orthotic, the lab name and address
  • Letter / form from you, explaining the biomechanical and gait analysis findings, the diagnosis and explanation of why this condition requires a custom orthotic. I also recommend a statement about the prognosis.
  • Receipt that the orthotic has been paid in full. The orthotic should not be paid in full until it is dispensed. If you take payment at the time of ordering the orthotic, you should consider this a deposit, which is then applied on the date of dispensing the receipt.

The patient will send these three items, along with the prescription and the claim form from their employer, to the insurance company. The prescription must not be dated before the dispensing date (the date the patient picked up and paid for the custom orthotic).

Custom orthotics are the missing link for many spinal conditions and help millions of Canadians get back on their feet and contribute to their community. I urge you to not be discouraged by tough economic times or difficult insurance requirements. Help your patients be the best that they can be from the ground up!

Dr. Lori Yarrow graduated from Canadian Memorial Chiropractic College in 1985 and received a bachelor's degree in exercise science in 1991 from the University of British Columbia. She has worn many hats during her professional career, including growing and divesting three chiropractic practices, teaching collegiate-level anatomy, pathology and neurology, and working as a professional project manager. Dr. Yarrow is currently the director of marketing strategy and education at The Orthotic Group and can be contacted with questions and comments at .

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