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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: 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



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



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.



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



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



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 



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



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



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.



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



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

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