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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:



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



From: Bill Beaton, DPM, Steven J. Kaniadakis, DPM


Unfortunately, this podiatrist signed a contract that did not protect him. The billing company that I have been using for years has a contract that states that they have a contractual obligation to submit all claims AND follow-up on all ARs, and they even pay for the EHR and practice management software. It's hard to prove lost income, but the podiatrist should have a lawyer send a letter demanding to know why claims were not paid. If the billing company doesn't respond or can't explain why, the podiatrist would probably have a good case for negligence.


Bill Beaton, DPM, Saint Petersburg, FL


Did you ever hear the expression, "Tell it to the judge"? Ultimately, the doctor signs the forms and is responsible for all the charges. It does not really matter that you are paying more or it is the best billing/coding people in the world. 


Steven J. Kaniadakis, DPM, Saint Petersburg, FL



From: Joel Lang, DPM 


While I am not an attorney, nor even a practicing podiatrist (anymore), it strikes me that the first responsibility you have is for the safety of your patients and staff. Bed bugs are a serious problem and can be transmitted readily. This patient has a serious contagious health problem and appropriate precautions must be taken to safeguard everyone in your office.


It seems a reasonable approach to require the patient to assure you that he is no longer a danger to himself, your patients, or your staff. You can resume his treatment once reasonable and credible evidence is presented that the danger no longer exists. This is not a question of discrimination; it is one of public health.


I also suggest that you enlist the aid of a company with a bed bug dog to again re-examine your office a few weeks from now to assure that the infestation is gone.


Joel Lang, DPM (retired), Cheverly, MD



From: Ron Werter DPM 


The important thing is not keeping the credit card numbers on file. I had asked our state podiatry society for a legal opinion on this (just another reason to be a member of the APMA). As it turns out, if there's any type of hacking or breach, or if the patient finds out that you are keeping the number at all, you can be subject to major fines.


The answer is to have your credit card processor keep the credit card number on their files. They are legally allowed to; we are not. There are various ways they do that, but basically when the patient comes in, you would enter their CC number or input their card to the CC company special site. Then Chase or Royal or whoever you use, has the number on their files. When the EOB with the patient responsibility comes in, you go on their secure site and submit the amount to them using the patient's name or special ID as if it was a new charge. You do not have access to the number; only they do. 


As for the particular form the patient signs, there are a number of examples on the Internet, but basically the form they sign is your giving them information and their giving you permission to charge them later. 


Ron Werter DPM, NY, NY



From: Joel Lang, DPM


I have great respect for Dr. Borreggine’s practices and knowledge, but I do not like the wording and tone of his “Podiatric Treatment Plan”. 


Though I am retired and practiced podiatry ‘when Lincoln was a child’, I don’t think people change that much. I always felt the doctor-patient relationship was much different from a customer-business relationship. A relationship with a patient is much more personal than the one they have with their home improvement contractor. 


Therefore, my documents and forms had a different...


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



From: Joseph Borreggine, DPM


This template is what we use in our office for our "high deductible patients" and can be used as a guide in your office. It should definitely be edited to fit the needs of a particular template you have in mind to create so that you can use it in your particular office setting.


Joseph Borreggine, DPM, Charleston, IL



From: Elliot Udell,DPM


Dr. Ravaei is correct. There are lots of malingerers who find the pathway to our offices. Dismissing everyone as being a faker is also not the right way to be. As a caregiver for elderly parents who need canes to walk to the curb, I appreciate the fact that some people indeed are handicapped and cannot walk distances. Each and every person must be evaluated as individual patients.


If a patient comes in requesting that we fill out a form for a DMV handicapped sticker and they need a walker or three-pronged cane to get into my treatment chair, they may have a valid request. On the other hand, if I am casting someone for "tennis" orthotics and that person asks for a handicapped parking permit, I will quickly show them to the door.


Elliot Udell, DPM, Hicksville, NY



From: Elliot Udell, DPM


In my 35+ years of practice, I have seen many patients who presented with foot pain along with a history of working in a warehouse all day on hard concrete floors. Since the query involves a legal matter, the question must be asked as to why "that" one employee developed the problem in that particular work environment and other workers did not. Were there other contributing factors such as abnormal biomechanics, loss of a plantar fat pad, obesity, or an employee willing to work all day in shoes with little to no padding.


Because most, if not all of the cases, I have treated with that same presenting history were not involved in litigation or seeking workers compensation, I was able to attain great clinical outcomes with these patients by prescribing either a better shoe and/or making them good custom orthotics with built-in cushioning. One caveat is that if you choose to go the route of orthotics, choose a lab that can and will make an orthotic with sufficient cushioning. Prescribing a rigid device for a patient as described, unless the problem is purely biomechanical, could make a bad situation worse. 


Elliot Udell, DPM, Hicksville, NY



From: Fay Mushlin


I have been using Backgrounds Online for many years. They are located in Sacramento California. They were referred to me from an HR company. Every employee that we hire signs a release to have their background checked. I personally work with Jennifer there, but everyone is helpful. You just call and set up your account and everything is then done online. The one thing that I like is you can always call there and they will help you with any questions.


Fay Mushlin, Newtown Square, PA



From: Michael L. Brody, DPM


The answer provided by PM News' editor is right on the money. Under the HIPAA rules, you are allowed to share patient information with other providers involved in their care. There are additional features of this aspect of the rule that you need to be aware of:


1. Patients do have the right to request that you do not share their health information with other providers.

2. Patients do have a right to request an accounting of all disclosures of their electronic health information. This means you should keep a log of each and every time you disclose their electronic health information.


In the example cited By Dr. Harris, I would take the following steps:

1. Obtain documentation that the orthotist is treating the patient. I would accept a letter from orthotists on their letterhead.

2. Make a note in the patient's record that the request was received, make the request part of their chart, and clearly document what information was sent to the orthotist.

3. Make sure the disclosure of patient information is logged in a manner that you can easily respond to any patient request.


This is not to be considered legal advice; you may want to check with your legal advisors on what process you should follow and what documentation you wish to have on file.


Michael L. Brody, DPM, Commack, NY



From: Donald R Blum, DPM, JD


The requirements are as follows:


(j) "Practice of Medicine" means the clinical prevention, diagnosis,or treatment of human disease, injury, or condition requiring a physician to obtain and maintain a license in compliance with the Medical Practice Act of a member state.(k)"Physician" means any person who: (1) Is a graduate of a medical school accredited by the Liaison Committee on Medical Education, the Commission on Osteopathic College Accreditation,or a medical school listed in the International Medical Education Directory or its equivalent;(2) Passed each component of the United States Medical Licensing Examination (USMLE) or the Comprehensive Osteopathic Medical Licensing Examination (COMLEX-USA).


I hope this clears up any issue about the Medical Interstate Licensing Pact.


Donald R Blum, DPM, JD, Dallas, TX



From: David S. Wolf, DPM, Steven Finer, DPM


What would you say to patient for tracking grease on your carpet? Really? "Please use these shoe covers on your next post-op visit and....we can book your contralateral foot on .....".


David S. Wolf, DPM (retired), Houston, TX


A patient brought her dog into the waiting room. The dog did its business on the carpet and the patient paid for the cleaning. 


Steven Finer, DPM, Philadelphia, PA



From: Gerald Mauriello Jr., DPM


I could not agree with you more, Dr. Kass. The current scope of practice in New York is absolutely ridiculous. What makes it worse, is that when you call the state, the woman who answers the telephone cannot tell me exactly what I need to do in order to achieve it. It is very confusing to someone trying to navigate the process on their own. As a new practitioner in New York State, I find this process almost laughable.


Just like in orthopedics, those who complete a residency, log the required cases, and achieve licensure in their respective state should then be allowed to practice their specialty. Instead, in New York, you are held captive and not allowed to practice unless you achieve this board certification. I thought my residency trained me to be the foot and ankle surgeon I am today. How does being board qualified or certified matter? Thoughts?


Gerald Mauriello Jr., DPM, MA, NY, NY



From: Richard A. Simmons, DPM


At the very least, I would send a letter to the Dean of Student Affairs at the college and simply spell it out to them what happened. I had this happen a couple of times and found that the colleges in our communities are very interested in maintaining a positive business relationship with local merchants, including physicians. My situations never involved foreign students. That said, your local Congressman or Senator should be able to put you into contact with someone at the State Department with whom you could file a complaint.


Richard A. Simmons, DPM  Rockledge, FL



From: Joseph Borreggine, DPM, William A. Wood, DPM, MPH


I recommend Kevin J. West, JD who is a legal consultant to PICA and the APMA.


Joseph Borreggine, DPM, Charleston, IL


I'm not an attorney, but I can relate a problem faced by some of the residents coming out of a surgical program and joining an orthopedic group. The group agrees to pay the podiatrist some salary (say $150,000 per year). The podiatrist agrees to put some amount of collectable revenues through the group practice (say $30,000 per month).


For the first 6-8 months, the group refers to the podiatrist and he/she is able to meet the monthly quota. Then, the referrals slow or stop and the podiatrist struggles and then fails to make his/her monthly quota. The annual salary may continue, but the unmet monthly quota is subtracted (monthly) from the account. If the podiatrist leaves the group practice voluntarily, he/she is still obligated for $30,000.00 per month for the duration of the employment contract.


Consider having the healthcare attorney you find specifically evaluate the contract for this scenario. Good luck! The coming years may be the best time in a decade to consider staying in or starting a private practice.


William A. Wood, DPM, MPH, Chicago, IL



From: Name Withheld


My attorney added the statement that "the lease would be null and void should Dr. ***** be unable to perform his medical duties in his usual manner." This seemed clear enough to me, however the landlord was ready to take me to court. While I was told that I would probably win, I ended up settling for $10,000.  


Name Withheld



From: Joseph Borreggine, DPM


Regarding this quandary, an insurance company can recoup monies within a certain time frame. That means they can only go back so far. This same thing happened to me last year due to an internal computer processing error. I had to pay back $35,000 to BC/BS of Illinois. They had to reprocess and pay the claims correctly. 


Here is a good reference for every state in the U.S. regarding health insurance payment recoupment. You will have to pay back these overpaid claims. Seek the advice of a healthcare attorney through PICA.


Joseph Borreggine, DPM, Charleston, IL



From: Name Withheld, Frank Marullo 


I and numerous other podiatrists in New York have received this type of letter from this carrier. Contact the New York State Podiatric Medical Association as I have done.

Name Withheld 

There are several variables that will decide whether or not you may or may not owe this money back. 


1. Are you an Out-of-Network provider? If so, this is to your ABSOLUTE advantage and you stand a much higher chance of winning this argument. Obviously, as an Out-of-Network provider, this would mean you provide services to commercially insured patients where 8-9 out of 10 have self-funded plans versus fully funded plans (FACT!). When treating patients who present a self-funded policy with Out-of-Network benefits, the insurance carrier’s (or Third Party Administrator/”TPA” in this scenario) “medical policies” are 100% irrelevant. They mean nothing to you. Their rules do not apply whatsoever. 


What matters is the beneficiary’s employer master summary plans description (Better known as the “SPD”). For every surgery you did on each patient, does...


Editor's note: Mr. Marullo's extended-length letter can be read here



RE: Treating Patients with Mental Illness

From: Richard M. Cowin, DPM, JD


A blurb appeared in the Orlando Sentinel on Sept.11, 2016, which was authored by Michael T. Morley, Esq., an assistant professor at Barry University Law School here in Orlando. In this article, Professor Morley states, “The Florida Supreme Court made it easier to sue doctors for malpractice. In Chirillo v. Granicz, a patient called her doctor’s office to complain about the side-effects of her antidepressant medication, including stomach pain. Her doctor changed her prescription, encouraged her to pick up some free samples from his office, and referred her to a gastroenterologist. 


The next day, the patient hanged herself. The patient’s husband and daughter claimed she “had not given them any indication that she might be suicidal.” The court nevertheless held that...


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



From: Larry Huppin, DPM


Just as Labcorp does, we require all of our patients to put a credit card on file (CCOF) if we are to bill insurance for them. We have required this of all patients for just over two years. The only patients who do not put a credit card on file are those self-pay patients who pay in full at time of service. 


Using a feature in our practice management system (Athenahealth), once each year, we swipe the patient’s credit card. Athena’s credit card partner (Elavon) stores the credit card information securely. The patient signs a one-year contract that gives us permission to bill that card for any outstanding balances. This is no different than having a...


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



From: Ayne Furman, DPM


I closed my office about 6 months ago. Here are some of the steps I have taken so patients can contact me in the future 1) transferred my office phone number to a VOIP line which is a less expensive monthly charge than a business line. I have this line coming into my home 2) posted a notification on my website (which I plan to keep active for several years) for patients to call or email me with questions 3) set-up a post office box so patients have an address to mail their requests for records. 4) maintained a fax number.


Ayne Furman, DPM, Alexandria, VA



RE: Forced to See Patients for Free?

From: Al Musella, DPM


I just received a letter about Health Republic. Health Republic is one of the larger insurance companies in our area, and apparently they just stopped processing claims on Nov. 5 without telling us. This letter appears to say that we are not allowed to balance bill the patients – that they are only responsible for the co-pay and deductible even though it looks like we will not be paid by the insurance company – or might get “modest payments.” Furthermore, it appears that NY State law says that we have to see these patients for free for the next 60 days if they go on a plan that we do not accept. The new plans start December 1, so all of these patients must be seen for free until then.


Could that be the correct interpretation?


Al Musella, DPM, Hewlett, NY



From: Arthur E. Helfand, DPM


Dr. Musella asks, "What is the history of the rules for routine foot care and mycotic nail care? Are any other Medicare-covered treatments subject to similar rules?" May I offer two reading suggestions that are in the current literature: 1. When Routine Foot Care Should not be "Routine" Part 1, Podiatry Management, October 2012, pages 163-173 and Part 2, Podiatry Management, January 2013, pages 189-198. and 2. Medicare - An administrative Perspective, Chapter 24, Public Health and Podiatric Medicine, American Public Health Association, 2006, pages 335-353.  


One also needs to go back to the original Medicare Law when we became a part of Medicare in 1965, including Section 1862a and the subsequent exemptions as regulations issued in 1970-1971, and 1984. You should find the information you are looking for in these documents. 


Arthur E. Helfand, DPM, Narberth, PA



From: Bryan C. Markinson, DPM


The new Novitas LCD has been bantered about for weeks now. I have had conversations with DPMs in other states. They told me that their state associations and CAC reps are silent and non-responsive. The fact is that no one has a solid reliable interpretation of the LCD. It's time APMA solves the confusion immediately. I don’t mean that we should start a fight to change it yet; we just need to clearly know what it means. For my preference, it would be great if we were all suddenly forced to tell Medicare patients that treatment for cutting mycotic toenails, fungal or not, painful or not will be on a cash basis.


Bryan C. Markinson, DPM, NY, NY



From: Neil Goldberg, DPM


An LCD (local coverage determinant) #L35013 issued 10/1/15 for 12 states covered by the Medicare administrator, Novitas, has dictated a series of provisions regarding mycotic nail care which are challenging to understand and implement. I guarantee that this LCD will be adopted by all other carriers shortly, so none of us are immune. It is clearly an opportunity by them to restrict such care. 


There are numerous components with which I have difficulty: 


1-Who mandated that...


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