Starting an O&P Practice: Fitting the Pieces

Throughout this series, O&P Business News has highlighted the steps to opening a new O&P practice. As with any puzzle, a business needs basic elements to be complete. For starters, a product.

O&P businesses have a multifaceted product — business owners’ first concern is helping their patients. To complete this task practitioners must fashion devices to meet each patient’s needs.

But how to create these complex and tailored products? Should business owners hire technicians to build devices in the office, or is it best to rely on an outside business whose sole function is fabrication? How does current technology work to get these jobs finished quickly and inexpensively?

Outsource the work

Starting an O&P Practice: Fitting the Pieces
© 2008/ Ivan

Ability Prosthetics & Orthotics Inc. — with facilities in Gettysburg and Exton, Pa., and Hagerstown and Frederick, Md. — relies entirely on outsourcing for its fabrication needs. In this model, practitioners are not limited to in-house fabrication options, thereby increasing patient treatment options and outcomes. Practitioners use standard O&P lab equipment and materials like a Trautman router, cutter and sewing machines inside the facility when modifying or adjusting devices.

Jeffrey Quelet, CPO, owner and vice president of Ability P&O, points out that “fabrication-centered” practices are not always worth the trouble. Aside from having to choose a location with significant square footage in an industrial area, owners must deal with material waste, by-products and emissions.

Buildings with those specifications do not exist in medical communities, he said.

“In addition to our own offices, we have surrounded ourselves with Class-A medical facilities to be closer to rehab facilities,” he said. “You don’t have that opportunity when you are focused on fabrication.”

Clark & Associates Prosthetics and Orthotics outsources its fabrication projects, but it does not travel far. The company’s main facility in Waterloo, Iowa is in the same building as O&P1, a national central fabrication organization. As president of both businesses, Dennis Clark, CPO, found this solution to be the most cost-effective option for his main and satellite offices.

In addition, Clark said that the decision to outsource the practice’s fabrication has benefitted both the business and his patients. Because of the flexibility that outsourcing provides, he has opened several Clark & Associates facilities in areas without a technical staff or even significant office space.

“It has made us much more responsive,” he said. “We can open [a facility] with less initial capital and with less staff, and provide the same high quality that our clients and referral sources are used to because [their devices are] being fabricated in the same place, and their care is being managed by the same clinicians.”

Also, most patients and their referring physicians are not partial to devices made by either in-house technicians or central fab locations, according to Clark, “as long as the manufacturer is directed by the practitioner that sees the patient.”

By founding a company with multiple comprehensive patient care offices, Quelet and Jeffrey Brandt, CPO, founder and president of Ability P&O, have removed the focus from fabricating devices and increased their focus on being clinicians. A reliable technological infrastructure allows for better communication across the four offices, corporate headquarters and manufacturers.

“Instead of having ovens, plastic and nonstandarized processes, we now have digital cameras, scanners, servers, laptops, and formally trained master’s-level practitioners that make fabrication efficient,” Quelet told O&P Business News.

This allows Ability P&O to create high quality devices without having to invest in additional equipment and training.

To C-Fab or Not to C-Fab

Established in 2007, Arise Orthotics & Prosthetics is a full patient care facility located within the Blaine Medical Center, a multidisciplinary medical center in Blaine, Minn., which includes spinal, vascular, pediatrics, family care physicians, radiology, physical therapy and an ambulatory surgical center. The decision to establish an orthotic and prosthetic practice within such a facility was made based on the inherent “down-the-hall” referral sources available.

Because of the increasingly competitive nature of obtaining referral sources and insurance contracts, clinicians can reap many benefits by promoting their practice as an extension of the surrounding medical community. Physicians and other medical personnel within the Center rely on one another to make the patient experience efficient and comprehensive.

Making the choice

The design of our O&P practice includes administration, clinical office, storage, two patient care rooms and full fabrication capabilities. Although we have the ability to fabricate all levels of orthotic and prosthetic devices on the premises, we have chosen to central fabricate the more labor-intensive devices such as CROW walkers and spinal orthoses. These items are modified on the premises; outsourcing the fabrication, however, allows time to focus on other business aspects of a new practice.

At this time, we have found that, with the increased labor and material components, these items are not cost- and time-effective to fabricate on the premises. Time spent fabricating must be weighed against time spent marketing and attending to other business needs.

When choosing a central fabrication facility, these questions should be considered:

  1. What is the minimum turn-around time of a device?
  2. What warranties exist and what is the complaint resolution protocol if there is a problem?
  3. How many shifts does the facility run and what are the hours I can send scans or fax information?
  4. Is there a template for devices or am I, as a clinician, able to establish my own templates?
  5. What are the shipping protocols? A well-priced central fabrication item can be overshadowed by excessive shipping costs.
  6. Does the central fabrication facility do all of the work on the premises or are items outsourced?
  7. Does the facility offer a volume discount?
  8. If the pricing is a la carte, are all upgrades necessary (i.e., applying Dacron to straps in the office instead of paying the additional charges)?

Choosing the best

Finding a central fabrication facility is easy. Finding a central fabrication facility that will provide the requested device for a fair price within the time constraints of demanding physicians is the hard part.

Interviewing facilities — from the customer service department to the technical supervisor — is important. I have called a facility during different times of the day to see their response time. If a central fabrication facility advertises 24/7 call response and fabrication, test to make sure that is true.

Because assisting Medicare patients also is a major part of my practice, I spend a considerable amount of time establishing company protocols to fulfill the requirements of the federal government. As the date of mandatory accreditation looms, the necessity of having policies and procedures in place is equally as important as patient care.

I have found the first 6 months of business ownership to be an exciting adventure. My wife, Teri, and I have taken our previous experiences in the field of orthotics and prosthetics and woven them into a company that we are proud to call our own.

Charles W. Kuffel, CPO, FAAOP, is the president and clinical director of Arise Orthotics & Prosthetics Inc.



Fabrication-centered practices must deal with material waste, by-products and emissions.

On the other hand, Lou Perrotta, CPO, owner of Perrotta Prosthetics and Orthotics in Canton, Conn., has found that it is more convenient, and often less expensive, to fabricate devices in the facility.

“If you pay a lab to do your work, by the time … the lab charges you, and you get the check from the network with your discounts, there is almost nothing left,” Perrotta said. After relying on central fabrication from the time his business opened in July 2006, Perrotta plans to move his fabrication needs in-house by the end of the year.

In yet another category of business owners, Brian Monroe, CPO, owner and president of District Amputee Care Center in Washington, D.C., uses both the in-house and outsource methods. He takes advantage of the extra patient time to familiarize himself with their specific cases.

“If I outsource some of the fabrication for things that are standard, it gives me more time to spend with the patient working on the socket fit,” Monroe said.


Computer-aided design (CAD) and computer-aided manufacturing (CAM) allow businesses to create and produce orthotic and prosthetic devices. These computer programs electronically create a design based on specifications gathered by the practitioner and entered by a CAD/CAM tech, and then manufacture the device with the production system’s built-in tools.

This system lets businesses efficiently communicate with central fab facilities.

“CAD/CAM is the way everything is moving,” Monroe said. “The days of doing hand casts … being around the noxious fumes and patients smelling the epoxy … [that] is not the way the field is going.”

This approach lets Monroe spend those extra hours with patients. Instead of devoting office time to fabricating devices for patients, he can ensure the proper fit and follow up as needs change.

Using computer software to alter devices is often less complicated, as well.

“If the patient has lost weight, instead of going through the entire process again, I can go back to the scanned image and reduce it in the specific areas and have a new socket for them,” Monroe said.

For Clark & Associates, CAD/CAM provides storage of thousands of patient files that are easily accessible to all of the company’s offices. This technology lets patients visit any of the offices without worrying about whether their charts have been sent by mail. Correspondence with third party payers, too, is sometimes quicker.

“Almost 100% of the time, we get approval [from the managed care organization] to make a new prosthesis when the patient has changed physically, because we submit comparable digital data from the old prosthesis to the new one,” Clark said. “We have that huge database, in house, all the time.”

This technology becomes useful when corresponding with referring physicians. When exchanging patient information, the O&P facility has all the necessary paperwork prepared and ready to send in a moment’s notice.

STARTING an O&P Practice

Compiling the Pieces
Making the decision to branch out, creating a business plan, finding a location and seeking advice from others

January 1 issue

Creating a Checklist
Obtaining a Medicare number and proper accreditation, finding and using valuable resources

January 15 issue

Puzzling Money Matters
Funding the venture, insuring the business

March 1 issue

Fitting the Pieces Together
Using central fabrication vs. fabrication technicians, buying essential equipment

In this issue

Completing the Puzzle
Opening the doors, marketing the practice, finding patients and referral sources, measuring success

August 1 issue


Other supplies

In general, supplies for any business should be decided on an individual basis. Even among different locations for the same business, material needs may vary.

To determine which pieces of equipment and other materials are necessary, new business owners should research the patient needs in that location, as well as determine the amount of money allotted in the budget for stocking the facility.

Additionally, business owners might consider client-friendly telecommunication service. Ability P&O has an 800-number for patients, referring physicians and payers to contact corporate headquarters should they need to ask administrative, nonclinical questions. In this way, patients reach people qualified to answer their questions, physicians receive status updates on patients and payers get answers to any authorization and billing questions they might have.

“This allows the clinician and the office staff to be a little more efficient,” Quelet said.

Practice management software, such as OPIE Software, compiles all patient information — clinical notes, patient images, L-code selection, patient demographics, physician information, insurance information, referral letters, etc. — electronically. Quelet appreciates the ability to access real-time data about any patient, without sifting through medical charts.

For new business owners, however, the most important aspect about making these decisions is ensuring the results will work with the individual facility.

“Central fabrication allows us to be more flexible in location, we don’t have to have quite as much expense and we don’t have to replicate staff from location to location,” Clark said. “But there is nothing wrong with doing it [another] way.” — by Stephanie Z. Pavlou

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