“A member shall only prescribe or dispense an assistive device for a patient when the examination and diagnosis or clinical impression indicate a condition within the chiropractic scope of practice that would reasonably benefit the patient from that assistive device. If a prescription has been ordered by another regulated health professional and is related to the chiropractic scope of practice, the member may dispense that device.”

CCO Standard of Practice S-021 Assistive Devices

 Assistive Devices Overview

There are many assistive devices that you might prescribe or dispense while practising within the chiropractic scope of practice. Assistive devices are those that support patients living with pain or disability to become more independent in their daily activities. These include orthotics, orthopedic braces, compression stockings, and back and cervical support products. Some of these products, such as braces, compression stockings and orthotics, come in both off-the-shelf and custom-made options.

There are additional products that you may offer for sale to your patients to assist them in gaining independence in their rehabilitation or overall wellness programs. These may include exercise equipment, such as therapy balls, balance boards, tubing for resistance-based rehabilitation exercises and TENS machines, as well as vitamins, herbal products or creams (e.g. topical analgesics). These may or may not be reimbursable through Extended Health Care (EHC) insurance plans or Health Spending Accounts (HSAs).

Ask your patients to check the details of their benefits plan or consult the Canada Revenue Agency’s Medical expense tax credit page to determine whether a product is likely to be reimbursable through an HSA.

 Clear, Complete and Clinically Supported Documentation

Assistive devices can be expensive, especially if a custom product is needed. It’s understandable that your patients will want to know the details of any insurance coverage they may have access to before committing to the purchase of the device. It’s also important that your patients understand the documentation and process requirements of their specific plan.

You can assist your patients by:

• Providing them with key information about the device (e.g. make, model, cost) as well as a copy of our Patients’ Extended Health Care Coverage Checklist, so they can make preliminary inquiries to understand the nature of their coverage
• Submitting a Pre-determination request on your patient’s behalf, where such an option exists. This is especially helpful for products with significant costs as this will decrease the likelihood of any issues arising with the claim after it is made.
• Providing them with documentation for Pre-approval, where this is required by their EHC insurer

In all cases, clear, complete and clinically supported documentation is essential.

For pre-approval or reimbursement an insurer will normally require:

• Prescription setting out a medical diagnosis from a health care professional authorized under the patient’s plan. The treating health care professional can assist their patients in obtaining timely and appropriate prescriptions by providing them with clinical documentation to share with the prescribing health care professional. This will help the prescribing professional understand the patient’s condition and needs.
• Itemized invoice from the chiropractor and receipt marked “paid”
• Itemized invoice/proof of manufacturing from the manufacturer

For orthotics, documentation should also include:

• Copy of gait analysis or biomechanical assessment
• Description of the casting technique, materials and process used, including make and model of a stock shoe being modified
• The date on which the device was cast, as well as the date it was dispensed
• Name of prescriber and name of the dispenser (if different)
• Date of payment

It’s also important to ensure that your patients understand that a product or device cannot be prescribed or dispensed simply because coverage for it exists in their EHC insurance package.

EHC insurance plans are “designed and intended to assist in providing coverage for the expenses of medically necessary services and supplies.”^[1] The College of Chiropractors of Ontario’s (CCO)’s Standard of Practice on Assistive Devices (S-021) stipulates that there must be a valid clinical reason for prescribing or dispensing these products.

Pricing and Billing for Devices

Set and adhere to specific prices for various services related to devices and provide itemized invoices. This makes it clear to insurers that your fees do not change based on your patient’s benefits plan. (For compassionate care exceptions please see Leading Practices: Billing and Receipts section.) Some insurance companies have begun to use their historical claims data to direct plan members towards providers whose pricing for services and devices falls within the insurer’s maximum reimbursable expenses.^[2]

CCO Standards of Practice stipulate the cost of orthotics and other assistive devices “must reasonably relate to the time and expertise of, and cost to, the member.”^[3] While this means you have some latitude to set your fees within these parameters, individual EHC insurance providers make their own decisions about whether reimbursement for devices will be subject to “reasonable and customary” fee limitations and, if so, what those limitations are.

EHC insurers determine their “reasonable and customary” amounts using their own historical and geographic data to determine the average cost to patients of specific products and services. If costs claimed for a product or service substantially exceed such “reasonable and customary” amounts, an audit or an investigation may be triggered. Insurers will seek to understand the reason for an apparent variation from the norm.  Another trigger could be if all or a significant number of your patients appear to be dispensed a particular device.

In most cases, insurers require invoices for assistive devices to be paid in the following order:

1. You pay the manufacturer or supplier for the device
2. Your patient pays you for the device and associated professional fees
3. Claim is submitted to insurer and insurer pays covered portions to your patient

If you issue an invoice marked “paid” to your patient prior to receiving payment, insurers consider this to be insurance Fraud because it asks the insurer to compensate the patient for funds the patient has not paid.

For more details and information on leading practices in orthotics insurance, we recommend you review the following excellent resources:

• OCA Orthotics Quick Reference Guide
• OCA Orthotics Insurance Best Practices Guide
• CLHIA Reference Document: Understanding Claims for Footwear and Foot Orthotics

Also, consult the CLHIA’s Service and Supply Provider Receipt Best Practices for Group Benefits Reimbursement. This document (discussed in Leading Practices: Billing and Receipts section provides detailed guidance on issuing receipts for medical supplies.

Patients’ Coverage Checklist for Orthotics or Other Assistive Devices

1. Does my benefits plan cover the product or device [make, model]?
2. The cost to the patient for this device is [cost].
   • How much of this cost will my plan cover?
   • Are there any fees, such as deductibles or co-payments that I should be aware of?
3. What are the terms and conditions of coverage that I should be aware of?
4. Do I need pre-approval?
5. Is a prescription required? Will my prescription expire after a certain time?
6. Under my EHC plan, which health care providers can prescribe the product or device?
7. Under my EHC plan, which health care providers can dispense the product or device?
8. Do I need to submit any other forms of paperwork or documentation to be covered?
9. For orthotics: What casting technique is required?