Orthotics and HMOs:   Many practitioners become dismayed that some HMOs will cover orthotics if they are made by local orthotists who are under contract to the HMO to provide these services. The HMO will not reimburse the podiatric physician to provide these services. In these cases I have tried to obtain a "carve out" contract to provide orthotic services to these HMO patients. When I write an orthotic prescription for a patient to take to their contracted orthotist, I specify the casting technique I want utilized (I always write for plaster casting with neutral suspension casting technique), I specify the orthotic I want fabricated (Lab and model i.e. JSB Eliminator II) the exact top cover material I want and any accommodations or modifications. Invariably when the patient returns from the orthotist’s office with their new devices, they are not what I prescribed. This triggers an immediate call to the orthotist, questioning why they did not follow my prescription. They usually give a song and dance why they cannot fill it and they substituted their orthotic for the one I prescribed. We would never stand for a pharmacist acting like this, why should we stand for an orthotist to do this? I then call provider relations at the HMO and voice my concerns that their contracted orthotists are not filling my prescriptions accurately and are putting my treatment plans for my patients at risk. I also have the patients call their customer service representatives and complain. This usually will produce a phone call from some one at the HMO trying to resolve the issue. This is where I make my pitch to provide orthotic services to my patients, enrolled in their HMO, in my office. I explain to the representative that this will accomplish three things; 1) Reduce the inconvenience to the patient, as they do not have to travel all over town to get the services they require (2) Assure that my medical treatment plan is followed accurately (3) Assure that the patent receives high quality orthotic devices made from custom casting performed by me. I then inform them of our office policy of "100% money back guarantee". I then inquire what fee they are paying the orthotist for these services, and if they are comparable to my fee structure in the office, I tell them I would accept this fee as an addendum to my contract. I have been able to obtain "carve out" orthotic contracts from several HMOs over the past few years.