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From: Ivar Roth, DPM, MPH


Missed first appointments were a continuing source of irritation in my practice. We now take a credit card from all first time patients and bill a nominal amount to make sure the card is real. This amount is deducted from their visit if they come in. We send a confirmation email immediately after they call with a copy of our policy so there is NO miscommunication.  


This has worked well for us. Those who refuse to give us a credit card do not get an appointment. This is a real simple solution. We only charge $75 if they fail to show up or give notice. This policy is really to keep the new patient mindful that our time is valuable when they book an appointment.


Ivar Roth, DPM, MPH, Newport Beach, CA

Other messages in this thread:



From: Lynn Homisak


I believe you are asking ‘should you bill a new patient you haven’t even seen yet?’ and ‘should you collect their credit card information prior to their appointment?' Instead of applying a Band-aid on an obvious problem and sending a negative message to patients before you even meet them, why not try to determine the reason WHY new patient cancellations are such an issue for you? 


Yes, new patients must occasionally cancel an appointment. It happens. It is not typical, however, to have a new patient cancellation "problem"; unless of course, new patients are scheduled so far out that...


Editor's note: Lynn Homisak's extended-length letter can be read here



From: Paul Kesselman, DPM 


There is no simple solution to this and there are multiple factors here. On one hand, asking for a credit card deposit on the phone does set a bad tone, but with high deductibles and co-payments and tight schedules, last minute cancellations are also unfair to other patients who otherwise would have been able to obtain care sooner. 


I agree that calling the patient the day before to confirm is far better than collecting a credit card "deposit" on the potential new patient. However, the reality is that tight schedules and last minute (24 hours is last minute) cancellations are unfair to...


Editor's note: Dr. Kesselman's extended-length letter can be read here



From: Elliot Udell, DPM


Dr. Secord shines a light on the fact that the exorbitant price of brand name medications charged by pharmaceutical companies to U.S. citizens could not be totally justified by the cost of research. Much of this research, as Dr. Secord points out, is done at institutions funded by taxpayers.


Even if we want to give an inch to big pharm's argument that research expenses are at the heart of why Americans pay so much more than "Canadians" for pharmaceuticals, it by no means explains how drug companies have cornered generics and raised the prices to astronomical levels. All of us are aware of how big pharm was able to exploit a legal loophole and start charging over ten dollars a pill for Colchicine when as a generic it sold for pennies for a tablet.


Econazole cream which is a generic antifungal, used to cost less than two dollars for an 85 gram tube. Somehow, the pharmaceutical firms were able to corner that market and raise the price to over $250 dollars for the same product. The ingredients in the EpiPen for which the company charges over $650 dollars (which we all have in our emergency crash carts) are available for less than $2 dollars. The bottom line is that the American citizens deserve close government scrutiny of what is going on and laws to protect its interests.


Elliot Udell, DPM, Hicksville, NY 



From: David E. Samuel, DPM


Several years ago, better vitamin therapy was introduced by a few companies that started showing better efficacy for diminishing neuropathic pain. You purchase the vitamins and resell them to your patients. You make a little on the vitamins and many times, patients feel better and are happy. 


Good clinical studies on it and biopsy, I'm sure, played a roll in determining what the vitamins ultimately did to warrant a trial with them. We have used these vitamins and some have seemed to give some moderate improvement and some have also not been helpful. It just depends on...


Editor's note: Dr. Samuel's extended-length letter can be read here.



From: Jeff Kittay, DPM


Hooray! Finally the Boards will be accountable to SOMEONE. The high-handed attitude that many state boards have exhibited against the members of our profession may at last be at an end. More than twenty years ago, I was the victim of such board abuse which cost me two years of aggravation and nearly $5,000 in legal expenses before the board rescinded their accusations of professional misconduct (I had had the nerve to suggest in a malpractice case against another DPM that he had indeed violated the standard of care, an opinion with which I stand).  


I was advised at the time by my attorneys that the board members had “governmental immunity” and could say or do whatever they pleased without fear of retribution and that I could not pursue them to recover my costs. Perhaps the removal of such immunity by the SCOTUS will put the Boards on notice that their actions can indeed have consequences and that they must be more careful when making accusations or levying punishments. Those board members that feel that they must resign in protest to being held responsible for their decisions should feel free to do so and will not be missed by the profession.


Jeff Kittay, DPM (retired), San Rafael Norte, Costa Rica



From: Michael Forman, DPM,  Joseph Borreggine, DPM


Thank you Dr. Evans for warning us about the North Carolina Dental Board v. Federal Trade Commission decision. I was under the impression, obviously false, that you could not be sued for stating your opinion. Perhaps this decision can be used to punish "hired gun" experts who testify whichever way they get paid.


Michael Forman, DPM, Cleveland, OH


This has been an issue for many years. Click here.


Joseph Borreggine, DPM, Charleston, IL 



From: Steven N. Solomon, DPM, JD, Raymond F Posa, MBA


With the latest Yahoo breach, encrypting your email is a great idea. As a medical practitioner though, you need to make sure that the people you're communicating with are using the same email system as you are. You also need to make sure that you have a BAA signed with the email provider so as to be HIPAA-compliant. You may find it easier to use a patient portal for your communications as it forces the people communicating with you to do so securely. 


Steven N. Solomon, DPM, JD, NY, NY 


I recommend Zix Corp ( to all of my HIPAA clients. It is fairly inexpensive and works seamlessly through Outlook. Also, along similar lines, if you need to encrypt your text messages, check out Tiger Text (


Disclosure: I have no financial relationship to either company. I just have years of experience with them and they are solid reputable companies that offer outstanding service.


Raymond F Posa, MBA, Farmingdale, NJ 



From: David Cutler, DPM


For those of you who prefer evaluating newer surgical procedures with a bit more published research behind them, look at the European orthopedic literature on MIS bunionectomy. Most of these procedures are variations on the same technique, namely a through-and-through metatarsal neck osteotomy with aggressive lateral translation of the capital fragment along with a unique stabilization of the capital fragment using a 2mm K-wire as shown here. 


Post-op X-ray of SERI Bunionectomy


There are several of these published studies dating back to the early 1990s, but the most expansive is by Giannini, et al. in International Orthopedics, September 2013 entitled "A Minimally Invasive Technique for the Surgical Treatment of Hallux Valgus; Simple, Effective, Rapid, Inexpensive (SERI)" (PMID 23820757) with 1,000 cases. At first glance, this technique seems prone to non-union, though in this study, none were reported. Dorsal malunion was observed though only in 8 cases.


I’ve been doing open bunionectomy techniques since I started practice in 1988, though with robust studies on MIS such as these, I’ve started doing the SERI technique over the past several months. It is trickier to perform than you might expect, though patients do experience very little post-op pain and minimal swelling compared to open techniques, and they do appreciate the smaller scar.


David Cutler, DPM, Bellingham, WA



From: Gary S Smith, DPM, Tip Sullivan, DPM


Unilateral edema in the absence of obvious pathologies is almost always caused by a DVT or a bulging disc in the lower back.


Gary S Smith, DPM, Bradford, PA


This sounds typical for early RSD -- now known as CRPS. The first line treatment is aggressive PT. You may want to get a second opinion if you have not seen much of this.


Tip Sullivan, DPM, Jackson, MS



From: Hal Ornstein, DPM


Every physician has experienced the situation where they need something from their back office assistant and they are not available. This situation happens numerous times each day in most practices and leads to us walking to finding the assistant or the infamous call down the hall to find them. Now there is a low-cost, low-tech way to solve this problem and ultimately enhance the efficiency of your practice. 


The concept makes use of inexpensive walkie talkies which are worn by the doctor and various members of your staff. The walkie talkies are worn on the belt or scrub suit with an ear bud and a microphone hanging at the level of the collar for the assistants and a microphone for the doctor. When you need anything from a staff member or have something you want heard in the back office, you simply...


Editor's note: Dr. Ornstein's extended-length letter can be read here. 



RE: ADA Section 1557

From: Raymond F Posa, MBA


To address Dr. Borreggine's and Dr. Rees' concerns regarding ADA Section 1557, the final rule has the same provisions as the HIPAA privacy rule, in that you must exercise a degree of reasonableness. The exact wording is: “Requiring covered entities to take reasonable steps to provide meaningful access to individuals with limited English proficiency. Covered entities are also encouraged to develop language access plans.” 


No where does it prohibit a family member from interpreting for a patient. So, especially in a small practice, having all sorts of interpreting skills in-house would be unreasonable. If your practice has a large percent of non-English speaking patients of one particular language, then it would behoove the practice to have a staff member who can translate. I see it all the time in practices that have many Spanish-speaking patients, or Russian or Hindi ones; they have staff who can speak their language.


So your language access plan can be as simple as: "In the event that we cannot communicate with a patient in their native language, we will rely upon an individual who accompanies the patient in their care, or in the case where that is not feasible, we will make use of telephone/Internet translating service XYZ." In most cases, this will be an infrequent occurrence. Also the offense occurs only if the patient files a complaint, so the key is to try to accommodate the patient in a way that the patient is most comfortable with - again with reasonableness and dignity.


Raymond F Posa, MBA, Farmingdale, NJ



From: Richard Rees, DPM


I am interested in how many doctors' offices are going to be compliant to HHS' new rule on interpretation requirements for each office on October 16th. For small offices such as mine, this could be a financial death sentence.


Richard Rees, DPM, Bellaire, TX



From: Philbert Kuo, DPM


I'm not sure about post-op shoes but there are CAM walker boots that accommodate up to that size. Brands include Bledsoe and Donjoy.


Philbert Kuo, DPM, Chesapeake, VA



From: James Koon, DPM


Like many, I am tired of this complaint. It is really, really simple: YOU are the doctor interpreting the LCD. YOU know what will and will not get paid by insurance. YOU know what is and is not medically necessary. YOU are responsible for the repayments if Medicare deems the service non-covered and you submitted a claim for covered services. 


If the patient is unhappy that their routine foot care is not covered then ask them the following question: "Mrs. Jones, are you asking me to commit fraud?” 


“But my other doctor gets it covered!” Response: "Then...


Editor's note: Dr. Koon's extended-length letter can be read here.



From: Michael M. Rosenblatt, DPM


Dr. Moglia expresses understandable irritation when CMS gives "contrary advice" to patients who contact them regarding coverage of routine foot care, inevitably making him appear incorrect when he says it is ONLY covered under (highly limited) specific conditions. 


I am reminded that the very same thing occurs when taxpayers contact the IRS and ask specific questions. The answers to those questions vary enormously and are almost always at "odds" with what your CPA stated. Your CPA says a circumstance is "black;" and the IRS says it is "white." There have been some studies on this very issue, and the replies from the IRS more resemble a dart-board in a bar where drinks have been free for the last 4 hours.


No matter what CMS says, if a DPM attempts to vary from the RFC rules excessively, there will be big trouble awaiting, no matter what CMS says or does not say. When patients bring this up, I think I would use the IRS metaphor as a direct comparison. No matter what CMS tells your patient(s), you do NOT "owe" them a personal professional healthcare prosecution to bend the rules so they can avoid paying you.  


Michael M. Rosenblatt, DPM, San Jose, CA



From: Brian Fullem, DPM


Dr. Steinberg, no need to call me out for bias. I stated that I have run in Hokas for 4 years and my opinion was being presented; by definition a personal opinion or experience is biased. I also do not believe calling 12mm drop old thinking is a negative thing. Different horses for different courses, maximalist is a new category, just like minimalist. I just recommended to a patient to switch to a 12mm heel drop instead of his current Hokas.


Dr. Steinberg, you are reading a little bit too much in what I wrote, I have no agenda and am not paid by any shoe companies.


Brian Fullem, DPM, Clearwater, FL



From: Brian Fullem, DPM


Hoka has made the largest increase in sales in the specialty shoe market several years in a row. Anyone interested in keeping up with the latest running shoe information should join AAPSM. Members currently enjoy a huge discount on Hoka, Altra, and 361 shoes.


Hoka has a rocker sole in addition to a 4-6mm heel drop and an extra amount of midsole material known as stack height. They are not only light, but you will not feel that you are elevated at all. I think this shoe is an excellent choice for plantar fasciitis patients as well as those with arthritic knee and hip joints. I have run in 4 different Hoka models over the last 4-5 years and love the shoes.


Altra is another newer shoe that all podiatrists should be aware of due to a wider toe box that mimics the shape of the foot, an excellent choice for patients with neuromas and HAV deformities. Altra features a zero drop as well. There is no difference between rearfoot and forefoot as opposed to the old standard where most shoes were 12mm; therefore, it is important to warn the patients to gradually break them in or they may suffer some Achilles or calf issues.


Brian Fullem, DPM, Clearwater, FL



From: Robert Kornfeld, DPM


Dr. Hecht asserts that if you reject private insurance panels and opt out of Medicare, your practice would be destroyed and you will go bankrupt. It's my assertion that if you don't, you will go bankrupt. Has everyone forgotten that health insurance is a product that the public purchases? Does it not stand to reason that if there are no docs willing to accept the crappy coverage that is offered, then the health insurance companies do not have a product to sell? If that's the case, would it then stand to reason that they will have to come up with a product that doctors are willing to accept so that they can then sell their product to the public? Reality check!


You cannot stand by idly watching the complete destruction of private, quality medical practice. That is victim mentality. And here is a guarantee. If you keep accepting insurance, they will continue to lower the fees. I have a patient who works for Blue Cross/Blue Shield. At the office, they routinely talk about how incredible it is that doctors are willing to work for nothing while the insurance companies get richer and richer off your backs. How much money do you spend trying to collect the money that is rightfully yours? Hello? Is anybody home? 


Robert Kornfeld, DPM, Port Washington, NY



From: Allen Jacobs, DPM


Your letter was not as shocking as you may believe. Here in St. Louis, we have multiple DPMs who regularly take their P&A procedures to the surgery center which they own in order to garner thousands of dollars to the center. They, of course, share in the profit.


When you wonder why we are being increasingly excluded from healthcare plans, ingrown toenail correction is one such example. Of course we all have the occasional patient who, because of age or anxiety, requires sedation for the performance of these procedures. But doing so 5–6 times weekly?


Allen Jacobs, DPM, St. Louis, MO



RE: AAOS and the Department of Veterans Affairs Provider Equity Act

From: James J DiResta, DPM, MPH


I believe the APMA letter from Dan Davis in response to the AAOS letter was well written and honest and a fair representation as to who we are and why we should be on par with MD, DO and DDS/DMD in the VA. Although the AAOS letter did impart some statements of truth, it also included inaccuracies. It was framed in such a manner as to be disrespectful to us as a profession, and as a whole is dishonest. The orthopedic community should be outraged by their society's initiative to hurt us in such a manner. In spite of this threat from AAOS, it amuses me that they are so paranoid of us as to behave this way.    


James J DiResta, DPM, MPH, Newburyport, MA 



From: Carl Ganio, DPM


After almost 3 decades in private practice, I now work for the VA as a podiatrist. The AAOS misrepresented the facts in my opinion. The Department of Veterans Affairs is well aware of the training and scope of practice of the podiatrist. Parity has nothing to do with the old turf battle between our professions. It has nothing to do with what we are capable of doing, procedures, the OR, etc. 


It is about being considered a “physician” by the VA. Our dental colleagues are included as physicians in Title 38… they follow the same pay scales that orthopedic surgeons do… Why not podiatry? Yes, It would allow for a salary bump in most cases… 


Editor's note: Dr. Ganio's extended-length letter can be read here.



From: Tip Sullivan, DPM, Robert Steinberg, DPM


I encourage all of my colleagues to read the letter posted in yesterday's article about podiatry in the VA system! Although the letter was biased against podiatry and I do not agree with the assumptions drawn, in truth, there were no misstatements made. I would love to see what APMA is writing to defend podiatry seeking parity at the VA.


Tip Sullivan, DPM, Jackson, MS


I would like to read the APMA's detailed response to this arrogant and deliberately misleading letter.


Robert Steinberg, DPM, Schaumberg, IL


Editor's note: To read APMA's response, click here.



From: Neil Scheffler, DPM, Patrick J Nunan, DPM 


I am not an attorney. In fact, I don't practice podiatry anymore, but for many years, I have believed that if a salesman in a store makes a diagnosis of a foot problem ("You have plantar fasciitis.") and/or treats a condition with, for example, orthoses, he/she is practicing medicine without a license. Podiatric medical boards have investigators who can be dispatched to substantiate these claims. The board can then ask the attorney general who works with the board to prosecute. I believe that a few prosecutions would shake up the industry sufficiently to minimize the problem.


Neil Scheffler, DPM (Ret), Estero, FL


People now have the ability to use a tablet to take a picture of their feet to make a 3-D printed orthotic. Several prominent podiatrists endorse the product that sells for $99. In this computer and social media age, along with vet high deductibles, patients will try these first. 


Patrick J Nunan, DPM, Savannah, GA



From: Lawrence Rubin, DPM


Kudos to Dr. Christina and APMA for their efforts to move podiatry into the era of value-based podiatric care. Nonetheless, because of antitrust and other prohibitory reasons, APMA cannot unite its members into negotiating groups at the local level where network inclusion or exclusion of podiatrists occurs. This networking is up to podiatrists themselves to create locally, and if they are not already looking for ways to do that, sadly in my opinion, that is valuable time lost.


Lawrence Rubin, DPM, Las Vegas, NV



From: James Christina, DPM 


Dr. Bondar asked for reassurance that APMA remains committed to advocating for its members with CMS, even in the wake of ICD-10. Dr. Bondar, you can trust that APMA is your advocate with CMS every day. APMA staff and member leaders are in regular contact with CMS, and we remain a staunch champion for our members and their interests, just as we were during the implementation of ICD-10. In the wake of the MACRA proposed rule, APMA has created a dedicated MACRA/Quality Payment Program information page for members at Also be sure to reserve your seat now for the MACRA Proposed Rule: A Look at MIPS webinar on May 24 at 8 p.m. EDT.


The Health Policy and Practice Committee will meet at APMA headquarters later this week to discuss numerous issues that affect APMA members’ bottom line, including MACRA, MIPS, APMs, and the future of healthcare reimbursement. During that meeting, the committee will explore the creation of a MACRA Task Force as well as the possibility of a summit to discuss potential APM models. APMA also is preparing formal comments to CMS in response to the proposed MACRA rule.


I encourage you to watch the APMA website and your Weekly Focus for outcomes from the meetings, as well as more information about MACRA and reimbursement issues in general. In the meantime, continue to count on APMA as your voice on Capitol Hill and at CMS. 


James Christina, DPM, APMA Executive Director and CEO