Diabetic shoes are of vital importance when it comes to preventing diabetic foot complications in at-risk diabetics. Their legitimate use in the medical community has led to the prevention of countless wounds, infections, and subsequent amputations. Unfortunately, diabetic shoes are over-utilized outside the medical community, as numerous medical supply companies, pharmacies, and even shoe retailers have taken upon themselves to profit from these products. This has led to a rash of fraudulent activity surrounding diabetic shoes, and may place the Medicare Therapeutic Shoe Bill in jeopardy.
In order for a diabetic to need diabetic shoes, they need to have some combination of neuropathy (nerve disease), foot deformity, callus or corn, prior foot ulcer, amputation, or circulation disease. If none of these are present, a diabetic does not need the shoe as the risk for foot complication is low, and Medicare will not cover it. A proper medical exam is needed to determine if these components are present, as a diabetic with any of these conditions should be under medical and podiatric care anyway. This can be done by the physician managing the diabetes, but a podiatrist usually handles this. A proper prescription for the shoes and a determination as to whether heat molded or custom inserts are needed is made, as well as a determination for any other modifications needed based on specific foot structure and deformity. At times, some diabetics have such severe foot deformities that a standard diabetic shoe is inappropriate, and a custom molded shoe is needed. This requires a much different process than what is being discussed here. After it is determined that a standard extra depth diabetic shoe is appropriate and the shoe prescription is created, the physician managing the diabetes then certifies the treatment of diabetes and the need for the shoe by essentially concurring with the podiatrist's exam assessment in writing. This documentation is required by Medicare.
The above process is often ignored when medical supply companies and non-medical entities are involved in the distribution of diabetic shoes. A common scenario takes place when patients are contacted by mail or phone by these companies (who are on a calling list due to their diabetes), and an offer is made for a "free" diabetic shoe. These patients are then fitted through the mail based on the shoe size they admit to, or they mail in a foam box impression of the foot sent to them. Events are also held in which patients go to a hotel or general conference center for a one-day opportunity to be fitted. Rarely is an exam performed by the dispensing company, who rely solely on the certification of the treating physician to be in-line with Medicare documentation requirements. Most of the time physicians are too busy to carefully scrutinize the source of the shoes, and simply want to provide protection to their diabetics, so they sign it. The patients are then sent the shoes, and no follow-up is performed by the company to determine if the fit is appropriate. If problems do develop, no one is available to inspect or modify the shoes. At times, the shoe styles used barely fit the qualifications for a diabetic shoe, as commercially available shoes are often used in place of a dedicated diabetic shoe, and the inserts used are of poor quality. Some companies will automatically use custom inserts whether or not they are actually needed as the custom inserts reimburse higher. All of this is done without the input or expertise of a foot specialist, or even the primary physician.
As if all this was not enough, in many cases companies will write off the 20% Medicare does not cover in the event a secondary insurance is not present (or will not cover diabetic shoes), in order to keep the marketing of "free" shoes accurate. This is illegal, as providers and suppliers are obligated to collect this.
In short, not all diabetics need diabetic shoes. Those who do will need shoes that fit properly based on their specific foot, and a podiatrist is preferred to create the actual prescription and follow-through with the product. Medicare needs to be billed properly and accurately. The over-extensive and fraudulent use of diabetic shoes for profit is threatening the long-term viability of this program. While the new durable medical equipment supplier rules initiated last year will help to reduce this fraud, there is still potential for abuse. To prevent this fraud, the determination for the use of these devices needs to rest solely in the hands of the podiatrist or physician treating the diabetes. The shoes should be dispensed directly from the podiatrist or from a skilled pedorthist/orthotist to ensure product quality and proper follow-up of fit and function. Any certification letter sent from a medical supply company, pharmacy, or shoe retailer needs to be carefully scrutinized by the physician treating the diabetes, and if in doubt, the physician needs to perform their own foot exam, or ideally send the patient to a podiatrist to ensure that the prescription is valid and necessary.