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02/06/2018    

RESPONSES/COMMENTS (MEDICAL-LEGAL)



From: Sean S. Ravaei, DPM


 



I get this request quite often from patients and I always decline. There is almost no evidence that this was caused by a concrete floor. I also get a lot of people asking me to fill out an application for DMV handicap placards. These are patients who are easily able to walk. I decline that too; they are both unethical. I see a lot of able people getting out of their car with a handicap placard. I think we as doctors need to do the right thing and stop being enablers. 


 


Sean S. Ravaei, DPM, Beverly Hills, CA 


Other messages in this thread:


10/20/2018    

RESPONSES/COMMENTS (MEDICAL-LEGAL) - PART 1C


RE: Requests to Trim Fingernails


From: Brian Kiel, DPM, John Fricker, DPM


 


One of the responders asked why as podiatrists we cannot trim fingernails. 60 years ago, we were chiropodists and treated the hand and foot (chiro-hand, pod-foot). We fought to change the name to podiatrist and now we are struggling to change the degree to MD. Going back to treating fingernails seems quite illogical.


 


Brian Kiel, DPM, Memphis, TN


 


I once had a patient who requested that I cut his fingernails. I replied that due to my scope of practice in Kentucky, everything I work on has to be below the knee. As he sat in the treatment chair, he thought for a second and then extended his hand down to his ankle and said, "How about now?"  We had a great laugh together. Clever guy.


 


John Fricker, DPM, Frankfort, KY

10/20/2018    

RESPONSES/COMMENTS (MEDICAL-LEGAL) - PART 1B


RE: Requests to Trim Fingernails


From: Bryce Karulak, DPM, Charles Morelli, DPM


 


I truly think we are hyper-focusing with respect to trimming patients' fingernails. I am willing to bet that if anyone of us cut a patient's fingernails and went to the majority of the PCPs in our respective areas, they would not care and even say, "Great!" 


 


Where this conversation should really focus on is enhancing our scope. I work in Texas and the law for podiatry basically reads, "A podiatrist may treat...


 


Editor's Note: Dr. Karulak's extended-length letter can be read here.


 



My question is very simple and I look forward to hearing from our legal scholars. Why is it that anyone can trim a fingernail but a podiatrist cannot? Why was my wife able to trim our daughter's nails? Why is a granddaughter not placed in peril if she cuts the nails of her grandmother in a nursing home? These examples are endless. Why might this not be covered under the Good Samaritan law which "provides basic legal protection for those who assist a person who is injured or in danger." I once had to pry open the hand of a patient in severe contracture, only to find a nail that was on the verge of puncturing his palm. Does that qualify him as being in "danger"? I submit to you that it does. 


 


Charles Morelli, DPM, Mamaroneck, NY


10/18/2018    

RESPONSES/COMMENTS (MEDICAL-LEGAL)


RE: Requests to Trim Fingernails


From: Daniel Chaskin, DPM


 


Trimming or debridement of fingernails might be interpreted as part of good podiatric care concerning a comprehensive podiatric exam in conjunction with podiatric treatment. The purpose  of such an exam is to ultimately treat the foot so that its condition remains as healthy as possible.


 


Look how far we came. In NYS, for example, podiatrists can cut above the malleolus to perform epidermal nerve fiber density (EFND) testing so long as the purpose of the exam is to treat a foot condition. The law says that we cannot cut above the malleolus, but I believe this refers to... 


 


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

10/16/2018    

RESPONSES/COMMENTS (MEDICAL-LEGAL)


RE: Requests to Trim Fingernails (Michael Lawrence, DPM)


From: Michael Forman, DPM


 


I agree with Dr. Michael Lawrence that there are times when we can further help an aged or infirm patient by cutting their fingernails. I understand why my colleagues have second thoughts about this because of malpractice issues, however to refuse this simple request would be horrid. I wish I could offer better advice. I admit that we have a few patients who have their fingernails trimmed in our office. I admit that I have a few dermatologists who referred patients to me for surgical correction of nail deformities. I performed these procedures although it may have been a foolish decision. And one more shameful admission, as a podiatrist who has an interest in the law and has studied law - I don’t even know if the state of Ohio allows us to work on fingernails.


 


Michael Forman, DPM, Cleveland, OH


 


Editor's note: PM News does not provide legal advice. The State Medical Board of Ohio has determined that an Ohio podiatric physician who has successfully completed appropriate training may, as medically appropriate, provide treatment of fingernail fungus in podiatric patients and for treatment of scars on the hand when the etiology is not associated with trauma.


 


Source: ohfama.org

10/12/2018    

RESPONSES/COMMENTS (MEDICAL-LEGAL) - PART 1A



From: Lawrence Kobak, DPM, JD, Todd Lamster, DPM


 


Dr. Morelli has a kind heart. He is a fine example of what a podiatrist and human being should be! Unfortunately, treating a wart on a finger is clearly out of scope in most states. More than one podiatrist has lost his license to practice in more than one state for doing this. 


 


Lawrence Kobak, DPM, JD, Uniondale, NY


 


I must admit that I am surprised by the number of my colleagues who perform this service. I, too, have elderly patients who ask me to trim their fingernails. I tell all of them that it is against the law because it is out of my scope of practice, and doing something out of my scope could put my license in jeopardy. Just because I am capable of doing something doesn't mean I have the right to do it. Every single patient completely understood and respected the answer.


 


To my colleagues who trim fingernails: Would you incise and drain an abscess on a hand or finger? Would you perform a biopsy of a suspicious lesion? Would you inject a symptomatic palmar fibromatosis?


 


Todd Lamster, DPM, Scottsdale, AZ

10/12/2018    

RESPONSES/COMMENTS (MEDICAL-LEGAL) - PART 1B



From: Paul Busman, DPM, RN


 



Like Dr. Morelli, I would very occasionally trim a patient's fingernails. These were generally patients that I had treated for a long time, had fingernails that were already pressing into their skin, and had severe disabilities. This made them unable to go to a nail salon. Some had such severe finger contractions that a nail salon would not likely want to treat them. Yeah, I know, scope of practice, liability, blah, blah, blah. I just didn't have it in me to refuse such a simple request which I was eminently qualified to fulfill. I never once had a problem doing this, just very grateful patients. Not that it legally meant anything, but I always told patients that their podiatry treatment was over, but I was cutting their nails as a friend might do. They got the message.


 


I never did treat warts on a patient's finger or any other area but the foot. However, I did tell them that if the warts on their feet were cured, there was a good chance that the warts would all go away. Know what? In a fair number of cases, that actually happened. Also, if I was treating a patient with some home applied remedy, e.g. Sal acid under occlusion, I'd point out to them that if they went to a dermatologist for their other warts, he/she might well prescribe a similar treatment for their other warts, wink, wink.


 


Paul Busman, DPM, RN, Frederick, MD


10/11/2018    

RESPONSES/COMMENTS (MEDICAL-LEGAL) - PART 1A


RE: Requests to Trim Fingernails (Maryann Trivlis, DPM)


From:  Brian Kiel, DPM, Tom Silver, DPM,


 


Sorry folks.. I am not a manicurist. Debridement of toenails is a valid medical issue but the fingernails do not (qualify). People can go to a manicurist for their fingernails. Are you going to file and buff them as well? 


 


Brian Kiel, DPM, Memphis, TN


 


Periodically, we get a request to trim a patient's fingernail that's split, thick, deformed/mycotic and if it just needs trimming, we take care of this as part of their visit-at no additional charge. When we notice that a patient's fingernails need trimming, as they are very long and they can't do it themselves-again we will do this at no additional charge. When we see a patient with dirty glasses...we clean them. If they need to have their shoes and socks taken off and put back on-no problem.  


 


We are in the business of helping people and we need to think of these things as just part of taking care of our patients. They appreciate it and this goes a long way towards creating happy, trusting patients who would never think of going anywhere else or referring friends/family to anyone else for their foot care.


 


Tom Silver, DPM, Golden Valley, MN

10/11/2018    

RESPONSES/COMMENTS (MEDICAL-LEGAL) - PART 1B


RE: Requests to Trim Fingernails (Maryann Trivlis, DPM)


From: Charles Morelli, DPM


 


While I completely appreciate and understand Dr. Block's measured and legal response to this query, part of me is in complete agreement with him but the other part is rolling my eyes at this. While a podiatrist is limited in scope (which does not include the trimming of fingernails), and medical malpractice does not cover these treatments, please don't tell me that a medically trained podiatrist who went through 3 years of medical and surgical training who is now a doctor and/or a surgeon would say no to an incapacitated and frail senior citizen who asks you to help them cut their fingernails.


 


Back when I made home visits, I did it whenever I was asked. In my heart I could never say no. In my private practice, I have stroke patients, or patient afflicted with Dupuytren's who are unable to do it and have nails that are on the verge of breaking the skin of their hand and their wife or husband would ask (sometimes plead) for it to be done. How could you possible say no. At least I could never and still don't. Anyone ever treat a wart on one of your patient’s fingers? 


 


Was I out of scope and was I opening myself up to the possibility of a malpractice case when they could have gone on to a massive fingernail infection and lose their finger or arm? Yes, I was, but my odds of hitting lotto or being struck by lightning were better than that. If you fear this, then just don't do it. 


 


Charles Morelli, DPM, Mamaroneck, NY

10/10/2018    

RESPONSES/COMMENTS (MEDICAL-LEGAL) - PART 1A



From: Stephen Doms, DPM, Martin S. Lynn, DPM


 


Five states do include the medical and surgical treatment of hands in podiatric statutes: Alaska, Minnesota, Michigan, Ohio, and West Virginia. Source: ACFAS state scope of practice provisions. I practice in Minnesota, and while I could trim fingernails and be within my scope of practice, I choose not to.


 


Stephen Doms, DPM, Hopkins, MN


 


I treat patients exclusively in SNFs and will only debride/I&D fingernails if they are dystrophic, mycotic, or have a paronychia. The durable power of attorney (DPOA) or patient is then informed that they should follow up with a dermatologist.


 


Martin S. Lynn, DPM, Snohomish, WA

10/10/2018    

RESPONSES/COMMENTS (MEDICAL-LEGAL) - PART 1B



From: Elliot Udell, DPM


 



Yes, hardly a month goes by when a patient does not ask me to cut his or her fingernails. On Friday, another tenant in our medical building came in an asked me to cut one of his fingernails. I refused. I still remember one of my professors at NYCPM, over thirty years ago, boasting to the class at what a good deed he did for an indigent patient by cutting her fingernails. The problem is that in most states, it’s against the law. Dr. Block said it well when he said that such an action could subject a podiatrist to professional discipline. 


 


I see no reason why our local state societies should not push for legislation which would allow podiatrists to cut fingernails but until this happens, we need to refuse.


 


Elliot Udell, DPM, Hicksville, NY


09/27/2018    

RESPONSES/COMMENTS (MEDICAL-LEGAL)



From: Tip Sullivan, DPM


 


In my home state, we do not have an independent podiatry board (yet). I have been involved in podiatry issues at the medical board level for many years. There are some issues when dealing with the board that are not fair - like the fact that you are not allowed to know the accuser or allowed to look at their record on you. That takes a court order and the court will most likely side with the board. 


 


Since the board investigators found no fault in your actions, I advise you to either have your attorney or you yourself contact the attorney for the board and discuss the matter. Perhaps bring it up at the next board meeting so the board may be able to find a way to prevent future issues in the way they handle complaints such as yours and maybe even correct your problem. Take an active part.


 


On a personal level, anytime I have a valid complaint, it bothers me-- board or no board! To have one that is frivolous would make me very mad, and I might try to petition the court to find out the nature of the complaint as well as the complainant.


 


Tip Sullivan, DPM, Jackson, MS

09/24/2018    

RESPONSES/COMMENTS (MEDICAL-LEGAL) - PART 1A



From: Richard Willner, DPM, Jeffrey Kass, DPM


 


While the reality is that the Data Bank reports to the NPDB are not meant to ever be removed except for a very limited number of occasions, based on the few facts that I have read in your publication of this date, I think that this podiatrist may fall into that area.


 


To begin to understand the NPDB, I suggest reading my latest article published on the NPDB.  It was published in BC Magazine (originally called Billing and Coding Magazine).


 


Richard Willner, DPM, New Orleans, LA


 


Name Withheld asks a valid question. If the complaint against him was found as “without merit,” then I agree with name withheld that nothing should be put on their record. If something is then [reported], the accuser effectively “wins”. This is outright wrong! This is something that should be corrected and changed. Why is the doctor always wrong, even when innocent? I say it time after time - why do doctors take this constant abuse? When issues arise that we may previously were unaware of, why doesn’t leadership attempt to evoke change before history repeats itself? I empathize with the poster. 


 


Jeffrey Kass, DPM, Forest Hills, NY

09/24/2018    

RESPONSES/COMMENTS (MEDICAL-LEGAL) - PART 1B



From: Donald R Blum, DPM, JD


 



When a complaint is filed with TSBPME/TDLR, Name Withheld should have been notified of the complaint. Assuming it was from a patient, you would have received a letter requesting a copy of chart notes and x-rays (at your expense).  At that point, you would have been made aware of who was the complainant. At that point, you have a limited [time] to forward the information to the TSBPME/TDLR.


 


Typically, your Medical Liability Company (I know PICA offers this service/benefit) will offer a defense for board complaints, or you can try to resolve this yourself. My issue to you is whether the information about the board complaint is whether it come from the National Practitioner Data Bank or from the TSPME/TDLR?  Did you tell the hospital that a complaint had been filed, the nature of the complaint, and that it had been resolved with finding the complaint showed no merit? You might consider going the NPDB website and do a self-search. If there is incorrect information, see if they have a mechanism to correct that faulty info. Did the NPDB show that the complaint was resolved finding no merit and was dismissed?


 


My recommendation has always been to send a letter to the TSPME/TDLR requesting a copy of the complaint with allegations filed with the board.


 


Donald R Blum, DPM, JD, Dallas, TX


09/11/2018    

RESPONSES/COMMENTS (MEDICAL-LEGAL)


RE: Administrative Fees?


From: Michael Forman, DPM


 


Recently, my wife was seen by her physician. The statement was sent to us indicating the service and the charge. In addition, an administrative fee of $44 was added. I had been under the impression that this non-covered fee was illegal. I thought I remembered that there was a legal case in Cleveland indicating the illegality of this charge. I feel that we should not be responsible for this fee, legal or not. 


 


The question I asked the biller was, “If a physician billed the patient $100,000 for an office visit - how much would the patient have to pay?" Obviously, the answer is not $100,000. More likely, it would be the usual and customary fee for that service unless the patient was informed of the cost prior to the service. Comments please.


 


Michael Forman, DPM, Cleveland, OH

07/19/2018    

RESPONSES/COMMENTS (MEDICAL-LEGAL) - PART 1B



From: Elliot Udell, DPM


 


There is a larger elephant sitting in the living room. When we use our e-prescribing tools, they automatically let us know what medications the patients has been prescribed by all of the patient's doctors. On the one hand, it is good because it would alert us if there is a dangerous drug interaction, even if the patient does not remember what medications he or she is taking. On the other hand, this represents an invasion of privacy and confidentiality.


 


Does this mean that any of us can punch in the name of any patient and find out what medications he or she is taking? What if a patient has a history of an embarrassing medical condition such as a sexually transmitted disease and does not want, "Dr. Jones" who is also a family friend to not know about that episode in his or her life? Don't the HIPAA laws protect this aspect of patient privacy?


 


Elliot Udell, DPM, Hicksville, NY

07/19/2018    

RESPONSES/COMMENTS (MEDICAL-LEGAL) - PART 1A



From: Donald R Blum, DPM, JD


 



Texas State Law effective 09/01/2019 (this applies to all physicians in Texas):


 


A new state law will require Texas physicians to check the Texas Prescription Monitoring database before prescribing opioids (hydrocodone, oxycodone, etc.); benzodiazepines (alprazolam or diazepam); barbiturates; or carisoprodol. Physicians must check each patient’s prescription history within the database for evidence of doctor-shopping or drug diversion. 


 


This means that surgeons must query the database before prescribing for their post-operative patients; and a primary care physician must query the database before prescribing for their sprained ankle patients or their stressed-out patients who need alprazolam.


 


The law does not apply to physicians prescribing for patients diagnosed with cancer or patients receiving hospice care.


 


Donald R Blum, DPM, JD, Dallas, TX


07/18/2018    

RESPONSES/COMMENTS (MEDICAL-LEGAL)



From: Michael Brody, DPM


 


My opinion (disclaimer: I am not an attorney and this is my opinion as a provider) is that unless you have a valid medical reason to query a registry about a patient, then the query could be considered a HIPAA violation. I do not believe it is reasonable to routinely query the registry prior to meeting the patient. If after meeting the patient, you develop medical concerns about the patient's use of opioids and feel this information needs to be taken into account, then it is valid to query the registry. 


 


One example where you might want to check the registry is if you are considering surgery on the patient, and usually prescribe opioids as part of the post-operative course, being aware of previous use of opioids may be valuable in...


 


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

07/09/2018    

RESPONSES/COMMENTS (MEDICAL-LEGAL) - PART 2



From: Allen Jacobs, DPM


 


We have always charged and received $20 per chart for requested records. Our office has always obtained full payment; in advance, I might add. Never, ever have we encountered any difficulty. On occasion, any reluctance to pay has been overcome with a clear positional statement of our policy to the requesting organization. In my experience, Dr. Kesselman’s advice and counsel in PM News regarding this matter is correct.


 


Generally speaking, a contractual obligation to provide necessary documents does not stipulate that such obligations be performed at your expense. You should recall that your contract is with the insurance provider and is NOT with the reviewing organization retained for auditing. Many states, such as Missouri, have enacted regulatory stipulations for minimum payment to you per CHART and/or per page or BOTH. 


 


Allen Jacobs, DPM, St. Louis, MO

07/09/2018    

RESPONSES/COMMENTS (MEDICAL-LEGAL) - PART 1


RE: HIPAA and the Opioid Crisis


From: Joseph Borreggine, DPM


 


There is an opioid crisis and epidemic facing this country and many states are requiring medical providers register with their prescription drug monitoring program and utilize it when prescribing any opioids or Schedule II drugs to patients. I was wondering how appropriate it is, with the current HIPAA laws, if a medical provider can investigate a patient's opioid prescription history prior to their coming into the office as a new patient or even if a prescription opioid is not being written? 


 


I ask because if a patient has an extensive opioid history that is unknown even in light of a pending prescription opioid Schedule II drug being written, then the care of this patient may become difficult in the future with respect to...


 


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

07/06/2018    

RESPONSES/COMMENTS (MEDICAL-LEGAL) - PART 1B



From: Daniel Chaskin, DPM


 



"The doctor must  provide such records at no cost to the carrier (usually stated in contract)." 


 


I disagree with Ms. Moracka-Sawaki's statement. My guess is that HMOs are getting paid a rate per patient that includes all administrative costs. One of those administrative costs includes the fees required to pay for the release of records. 


 


1. If podiatrists are not being reimbursed for the release of such records, then the actual fee received by the HMO from the federal government should be proportionately reduced by such an amount since the HMO is not paying for such records.


 


2. There are Stark laws that may come into play. To have access to a patient population by a contractual provision that waives the right for a provider to charge for a record release just might depart from federal law. As a suggestion, perhaps the APMA can investigate if all podiatrists are legally entitled to bill for such records. It just might be illegal to deny payment as per a contractual clause that might not be in compliance with federal law. 


 


Daniel Chaskin, DPM, Ridgewood, NY 


07/06/2018    

RESPONSES/COMMENTS (MEDICAL-LEGAL) - PART 1A



From: Paul Kesselman, DPM


 


With all due respect to this recent posting, just about every PCP and MD/DO specialist I have spoken with over the last few years who has asked for money has received payment from the third-party requesting the charts on behalf of the carrier. And all have told me that the carriers involved (excluding Humana) provided no resistance. Unless otherwise precluded in your contract, you have every right to ask for payment and what does asking really cost? I can’t speak for interactions with Humana as I am not a Humana provider and not privy to their contractual obligations. 


 


Of course, whether they pay you and/or decide not to pursue further inquiries for charts now or in the future is quite another story. Asking costs nothing! Not asking costs you quite a bit!


 


Paul Kesselman, DPM, Woodside, NY

07/04/2018    

RESPONSES/COMMENTS (MEDICAL-LEGAL)


RE: Charging Insurance Companies for Chart Reviews


From: Steven Frydman, DPM


 


Five years ago, I talked to a supervisor at Humana (Medicare Advantage) about getting paid for the charts that were being requested for review. Every 2-3 months, they requested 20-30 charts. He said that he would have to check with higher-ups and get back to me. I did not hear from him and the requests stopped. I thought I had succeeded. About 6 months later, I received a registered letter stating that I was no longer needed as an in-network provider. I appealed the action, but they stated that there were enough DPMs to service their population. I was not an out of the ordinary biller or over-utilizer. I wonder why this happened. Coincidence?


 


Steven Frydman, DPM, Milwaukee, WI

06/29/2018    

RESPONSES/COMMENTS (MEDICAL-LEGAL)



From: Paul Kesselman, DPM


 


This issue is not based on one's state limit as I believe those regulations only apply for patients wishing to access their medical records. I don't believe these apply to insurance carriers or their delegated contractors requesting information. I'm sure if you review your managed care contracts, you won't find that there is a preclusion for charging them for this information, only that if requested, information must be provided. 


 


Furthermore, the insurance carriers (or their third-party intermediaries) are harassing doctors by requesting an inordinate amount of records in a very short time frame. These requests are purely based on the carrier's greed so the carrier can potentially assign patients to a...


 


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

06/03/2018    

RESPONSES/COMMENTS (MEDICAL-LEGAL)



From: Donald R Blum, DPM, JD


 


This program might or might not be in compliance. I recommend that you consult an attorney who is protecting your interest, not the interest of the company. Please remember that in addition to federal laws, there are state laws that could apply.


 


Donald R Blum, DPM, JD, Dallas, TX


 


Your antenna certainly may have picked up some very bad signals. This definitely sounds like it is a "pay for play" and a clear violation of not only Stark but numerous anti-kickback regulations, the latter of which are applicable to all patients and not simply to those on Medicare. In order to keep from running afoul of these complex regulations, you may wish to obtain a copy of the agreement (or any agreements from vendors) and forward them to a healthcare attorney who is well versed in Stark and anti-kickback regulations. The fee you pay to an attorney is priceless. Otherwise, simply steer away from such agreements as most of these are not worth the trouble. The key to remember with the types of arrangements you mentioned is that no matter how much they pay you, defending yourself and paying any applicable fines may surely bankrupt you. 


 


Paul Kesselman, DPM, Woodside, NY

05/21/2018    

RESPONSES/COMMENTS (MEDICAL-LEGAL)



From: Matthew B. Richins, DPM


 


I had this exact same problem with my billing company. They are happy to bill all your clean claims, but are reluctant to work on denied claims or go after secondary insurers. Think about it. If you got paid the same to debride nails as you did to do a bunionectomy, would the business side of your brain ever want you to step into the OR again? Why would they want (and why would you expect them) to work harder for less money? Once I realized this, I hired a biller and did it all in-house. 


 


After I hired my biller, her first month on the job was to learn the ropes and to figure out how to bill podiatry. I told my billing company that...


 


Editor's Note: Dr. Richins' extended-length letter can be read here
Winlind52