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From: Bret Ribotsky, DPM


I’ll take the counterpoint to my friend and Boca Raton neighbor, Dr. Sherman. Live CME events are best. Not only have I had the opportunity to have lectured in 49 of the 50 states and many 15 different countries, but I have also been the patient for multiple foot operations. For the months after my accident, I spent many months in rehab, unable to walk, and did many online classes. I collected online training certifications in real-estate, insurance, financial planning, securities series 7, 63, and a bunch more. But... there is nothing as good as live learning. And as a physician, there is so much more to learn at a seminar than what is learned in the lecture hall. I have learned so much in the hallways, and at the bar from my colleagues. Meet the Masters was started 8 years before my injuries, with the idea that learning outside of the lecture hall was priceless.  


I do enjoy online events, but I would hate to miss the yearly get togethers to learn from and with others. As a patient, I know the difference between great and outstanding care; that it comes from those with exposure to many viewpoints which only a live event can deliver.  


Bret M. Ribotsky, DPM, Boca Raton, FL

Other messages in this thread:



From: Kenneth T. Goldstein, DPM


I totally agree with Dr. Udell. Years ago, when a patient didn't want to pay a bill, they threatened to sue. Now-a-days they threaten to post a "nasty review"(because it will cost them money to hire an attorney). The fact that this patient not only wanted the fees removed, but also a DISCOUNT! is absolutely ridiculous. Should you give in, this person sounds like they will write the negative review anyway and say to themselves - "Gotcha".


You have done all of the correct manners and given more than enough time for this patient to pay. At this point my answer would be - It is out of my hands and the collection company has control of your account.


Kenneth T. Goldstein, DPM, Williamsville, NY



From: Jarrod Shapiro, DPM


I'm writing in response to Dr. Sherman's comments about online CME. I agree with his comments and support the opinion that online CME should be unlimited in all states. Simply put, the content and delivery is the same, the requirements for proof of viewing is higher than at live conferences, and this delivery method is appropriate for adult learners. The various online CME available allows a physicians to receive rapid answers to topical clinical problems using on-demand education services. This format is innovative and able to change with developing technologies. Allowing online CME to flourish is equivalent in the medical community to the progress of the Internet itself. This system must be allowed to develop.


Disclaimer: Dr. Shapiro writes the column Practice Perfect for PRESENT e-Learning Systems.


Jarrod Shapiro, DPM, Pomona, CA



From: Dennis Shavelson, DPM


I am a 71 year old practitioner and find myself more and more successful attracting millennial patients by marketing how I practice.

  •  I offer holistic cures, not just tunnel vision Band-Aid care.

  •  I offer care of treatable underpinning pathology (medical, biomechanical and   kinesiological).

  •  I practice Prevention, Performance Enhancement and Quality of Life Upgrading.

  •  I offer more seamless office visits and availability in the cloud.

  •  Rather than state that I treat everything for every foot, I market niche compartments of diagnosis and care (biomedical engineering and ugly toenail cures).

  •  I have hardship and sliding scale fees available.  

Dennis Shavelson, DPM, NY, NY



From: George Jacobson, DPM


Since this topic has come up again, I would like to remind everyone of a posting that I wrote on 03/05/2016. You can search it in the PM News archives. In a nutshell, here is the main excerpt, "We received a letter from Palmetto GBA stating that they have received information from the National Supplier Clearinghouse (NSC) indicating  that we have not billed the Durable Medical Equipment Medicare Administrative Contractor (DME MAC) within the last four consecutive quarters."   


George Jacobson, DPM, Hollywood, FL 



RE: Enough Already with Time-Consuming Chart Requests (David P. Luongo, DPM)

From:  Cynthia Ferrelli, DPM


I have experienced the same problem, so I came up with a solution several months ago that has been working fine. When my office is called for a chart review, we say we will comply but that their reps come to my office, will have to pull all the charts themselves, and find what they need in the chart. We tell them that this is how we do it and we set the guidelines. Set your boundaries. You are paying your staff to do work for you, not for the insurance companies. We seem to do enough of that already.


Cynthia Ferrelli, DPM, Buffalo, NY



From: David Gurvis, DPM


I also have a missed appointment fee. I find the “threat” alone reduces missed appointments. Do I apply the fee uniformly? No. Actually, I hardly ever use the fee unless a patient has been egregious in repetitive missing of appointments. What I find then is that if I apply the fee, the patient goes away. The desired result. They fire me and I don’t have to discharge them!


I don’t have the fee on new patients as it is too difficult to make sure that they understand my policy, but if they miss two appointments, I refuse to take them back. As always, there is common sense. Missing an appointment without a call later is frowned upon more than missing with a call later that indicates the patient is sorry and had a lapse in memory or perhaps a real reason.


David Gurvis, DPM, Avon, IN



From:  Brian Kiel, DPM


I have a different perspective on this issue. Even though it can be aggravating to have no- shows, perhaps you are better without them in the first place. Those who do that frequently will be the ones who will not follow instructions for care, especially post-op or with wounds. I prefer not to have those patients in my practice. Also, another aspect is that we do slightly overbook on purpose and when there are no- shows, which happens every day, it leaves me a chance to "catch up.


Brian Kiel, DPM, Memphis, TN



From: Paul Busman, DPM, RN


I wouldn't require a credit card guarantee. Right off the bat, even before you'd established a doctor-patient relationship, you'd have shown distrust for that new patient. You've also suggested that getting their money is more important than taking good care of them. Missed appointments are a fact of life.


A better way would be to call that potential new patient the day before the appointment and remind them of the date and time, and tell them how much you're looking forward for the chance to care for them. 


Paul Busman, DPM, RN, Frederick, MD



From: Paul Kesselman, DPM


When Medicare Part D first was announced, I was asked to research and write an article on the subject. To my astonishment and much to my chagrin, the pricing of drugs was not set by the government but by private insurance carriers and the industry. This and other issues such as the donut hole, deductibles, etc. have left many seniors in a position of having to choose  food or medicine. 


Many split the doses of medications which may have not been engineered for such a procedure. Some I am told even end up in the ER due to the untoward toxic effects of the resulting...


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



From: Bradley Bakotic, DPM, DO


I'm a bit confused by the post related to ENFD by John Hurchik, DPM and some of the subsequent responses, particularly that offered by Elliot Udell, DPM, who seemed to imply that clinical doctors, and their labs, are doing ENFD testing strictly for "massive" financial gain rather than optimal patient care. 


First, let me say that I have been informed that Dr. Hurchik did intend for his note to take the negative tone that it seemed to. Secondly, those that believe that a punch biopsy pays a "massive" amount of money, probably have never done a punch biopsy. The "massive" reimbursement for a punch biopsy is about $85.00. It might buy you...


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



From: Ed Cohen, DPM


I think if the patient has a good hgba1c, the procedure is safe. The nerve biopsy is slightly more accurate than a Sudoscan. The Sudoscan is a three-minute test where patients step on plates while placing their hands on other plates. I  think the Sudoscan is accurate enough to give you a good diagnosis and has the advantage of not having to treat a biopsy wound. Another great advantage the Sudoscan has is that you can safely run the test on any diabetic patient no matter how high their blood sugar, and the equipment can never cause an infection.


The  patient is usually more receptive to a non-invasive test and the Sudoscan is a good practice builder. The downside is insurance reimbursement, which used to be very good, but has now become a problem in the last few months. In some states, podiatrists are not authorized to use the machine. I have found the Sudoscan a great objective tool to evaluate the effectiveness of my treatments and selling the various nerve food products to the patients can also be a nice revenue generator. Patients also don't mind paying for the test when it is not covered by insurance.


Disclosure: I have no financial relationship to Sudoscan.


Ed Cohen, DPM, Gulfport, MS



From: Martin S. Lynn, DPM, Jay Seidel, DPM is an excellent resource, providing options such as email destruction after a pre-determined time.


Martin S. Lynn, DPM, Oil City, WA


I use G Suite. It's the paid version of Gmail, Calendar, and Drive. You can sign a BAA with them and they are HIPPA- compliant. Also, it looks more professional, as you'll have Pricing starts at $5/month per user for 30gb of storage, and for another $5/month, storage is unlimited.


Disclosure: I have no financial interest in Google's products.


Jay Seidel, DPM, Baltimore, MD



From: Jon Purdy, DPM

There are a number of ways to achieve better patient flow in an office. Some are more expensive with installed lights or computerized options within EMR systems. There are less expensive manual colored flags that hang outside patient rooms and used as indicators for what is to occur in that room. I feel tthat the system I have always used in my practice is even more simple and effective. 

I have designed a “task sheet” which is a categorical list of our most common diagnostic and therapeutic procedures, dispensed items, medications, and other “tasks” that I perform. This sits in the chart holder outside the patient room. If it is vertical and backward, I know this is the next patient to be seen. I take it in the room and fill out what I need performed for that patient. My assistants then know to orient the task sheet of the next patient to be seen, from horizontal to vertical.

When I walk out of the patient room, I place the task sheet vertical and forward. The assistants perform and prepare what I have checked off, such as x-rays, injections, medications, and bracing, as I walk into the next room, which has a vertical task sheet. By the time I am done with that patient, the tasks I have marked for the previous patient will have been performed and initialed. I can finish up with that patient and mark any additional tasks needed - and the process continues. Of course all HIPAA compliance is followed, so no patient identifiers are visible. Theoretically, one could see and treat patients without ever having to verbally communicate with the well-trained assistant.

Jon Purdy, DPM, New Iberia, LA



From: Vince Marino, DPM


As I was reviewing ADA Section 1557, I came across this on the HHS website, which I would like others with more knowledge to comment upon. Is it possible that we in private practices might not be considered a “Covered Entity” according to the definition from the Office of Civil Rights, and hence be excluded from section 1557 compliance?


Civil Rights Obligations of Covered Entities - Nondiscrimination laws enforced by the Office for Civil Rights (OCR) prohibit discrimination and require covered entities to provide individuals an equal opportunity to participate in a program activity, regardless of race, color, national origin, age, disability, or (under certain conditions) religion or sex.


What is a Covered Entity? - A Covered Entity is any entity that receives federal financial assistance from the Department of Health and Human Services or is covered under Title II of the Americans with Disabilities Act as a program, service, or regulatory activity relating to the provision of health care or social services.


How do you know if you are not a Covered Entity under OCR jurisdiction in its enforcement of nondiscrimination laws? If you receive some type of federal financial assistance from another federal department or agency but it does not include any HHS assistance, you are not a covered entity under OCR’s jurisdiction. You may also not be such a Covered Entity if you are a healthcare professional who accepts only Medicare Part B insurance payment. (Bold and Italics added by me.)


Vince Marino, DPM, San Francisco, CA



From: Robert Wunderlich, DPM


I have a patient who wears a size 17, and I was able to fit him into a Darco Body Armor Walker II. This was the only walking boot I could find that would fit him. Gill carries them in both a high and low model. If that doesn't work, another option would be to put him in a short-leg walking cast, or perhaps a slipper cast.


Robert Wunderlich, DPM, San Antonio, TX 


Editor's note: This letter has been reprinted from PM News' archives.



From: James Lucarelli, DPM


What I have done to solve this problem is copy the LCD from my Medicare carrier and highlighted certain parts. If patients complain about wanting to be seen sooner, I show them the guidelines regulating the 60-day global period. They can pay cash if they want to come sooner. Just like your situation, I will show them what the Medicare guidelines consider RFC - i.e. corns and calluses. If I have a diabetic patient who does not meet the guidelines, I will show the patient the guideline in print, as well as show the covered diagnoses and class/clinical findings required.


If the patient tells me "they" said it would be covered, I tell them to get that person whom they spoke with on the phone to send it to me in writing that they now cover this service and it now supersedes the previous long-standing published LCD. If that doesn't work, I wish them well and tell them they can shop around for another doctor who will do what they want but I am not going to lose my license, be fined, or end up in jail just to make them happy.


James Lucarelli, DPM, New Bedford, MA



From: Bryan C. Markinson, DPM


This problem goes way beyond having CMS employees telling Medicare patients wrong information about coverage policy. The IRS is famous for giving wrong information on tax rules to the public. I am sure most gov’t agencies have similar deficiencies in transmitting accurate information to the public who are simply trying to understand and comply with the rules. 


The routine foot care issue, however, is plagued by so many other confounding problems. For example, the right for regional Medicare carriers to interpret federal CMS guidelines independently. While being on warfarin is a recognized risk factor and acceptable for routine foot care in one part of the country, the same patient’s care is medically unnecessary (and potentially fraud and abuse) in...


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



From: George Jacobson, DPM


The original post and my post were not referring to the utilization of the shoes for runners. They're two separate discussions. I think that all respondents may agree on this and that perhaps we can help some of our patients who are working on their feet for a living. We make our recommendations to individual foot types and pathologies, and we don't want to over- generalize in our discussions.


I don't recommend individual shoes (brands). I educate my patients about what qualities to look for due to their pathology, and have samples of different types of athletic shoes in the office. I also cut some athletic shoes longitudinally in half (sagittal plane)  to help with their education and understanding. Some patients say they have good athletic shoes at home and then bring in a flimsy, flexible "sneaker" (Keds). They can intuitively see the difference with my sample.  


George Jacobson, DPM, Hollywood, FL


Editor's note: This topic is now closed.



From: Helen Gentile, DPM


I am a retired podiatrist who is now a personal trainer/TRX instructor. I had a severe forefoot injury this past winter that required a walking boot for 6 weeks, and I still had significant residual pain. I found Hoka One Shoes and they were like a magic pill. Within about 10 days of use, my forefoot pain had significantly reduced to the point that I could start running again. I resumed my full schedule of teaching and my personal exercise schedule.  


The Bondi model is one of the max cushioned models I use. Hoka One also has models for trail running, spikes, and hiking shoes. The main drawback of the Bondi model is that there is very poor lateral stability due to the very thick sole. I do not recommend it for any sport that involves a cutting movement or unstable surfaces. I love these shoes and the fact that I can now run without foot or knee pain. 


Disclosure: I do not have any financial relationship with Hoka shoes.


Helen Gentile, DPM, Avondale, PA



From: Peter Bregman, DPM


Until we show the public the belly of the beast (much like the cigarette commercials that show all the negative effects and the addictive nature of nicotine), we cannot fight it. The system is corrupt and the public just keeps bending over and accepting more co-pays and higher premiums. If we were to show the public in paid TV commercials how much we bill and how much we get back on most things, they would be as sick as we are. Let’s show them the denial of MRIs and other studies based on some guidelines the insurance companies produced. 


Put the salaries of the board of directors/CEOs of each insurance company showing throughout the commercial. Then show the 5-10 dollars we get for an office visit (with their 40-50 dollar co-pay) and maybe there will be some outrage. Until Joe public decides not to take it anymore and understands that the system is corrupt, there will be no change! This whole mess forces doctors to game the system which is why you can get 10K for a P and A. The system is the problem, not the doctors. If we were paid what we are worth for our time, education, and effort, we would not have to do things that seem ridiculous to most. Sure the greedy would still do it, but I think most would not.


Peter Bregman, DPM, Las Vegas, NY



From: Neil H Hecht, DPM


I am not surprised at Dr. Lloyd’s comments. Nor am I surprised at the reimbursement levels for his surgical care and the associated hospital charges. Further, I am not surprised regarding his own insurance premiums increasing 29%. What surprises me is that any of us continue to work in this system. I am as guilty as anyone in that regard. I was a hospital-associated wound care doc for 20 years in addition to my private practice, and felt I had to accept any and all “comers” to our clinic and as inpatients. I enjoyed the work immensely and felt I was doing some good for the patients. 


However, all of us who continue to accept private insurance and Medicare have now watched the downfall of private practice medicine on such a steep slope that I feel some form of “shell-shock” (that’s an old term for “battle fatigue”, another old term for post traumatic stress disorder!). I believe that most of us docs are NOT in a position, as has been suggested, to reject private insurance panels and opt out of Medicare because this would destroy our practices and force bankruptcy for all practical purposes.


Pathology mandates care. Care requires material and manpower. Material and manpower (that’s us and our offices, folks) costs money. The money has to come from somebody, most often third-parties and the government. So, if Dr. Lloyd wants real change, exactly what does he suggest on a real, daily, practical basis that is viable? As a matter of fact, what do all of you in the medical professions suggest? I’m all ears!


Neil H Hecht, DPM, Tarzana, CA



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

From: Bret Ribotsky, DPM

I think the real issue is that AAOS is getting involved in a problem that they cannot solve. There are no full-time orthopedic foot and ankle surgeons at the VA vs ' 400 full-time DPMs. There are 16 part-time foot and ankle orthopedic surgeons versus over 1,000 part-time DPMs in the VA system. Since the VA (in reality) pays much less than private practice, adjusting DPM salaries has nothing to do with preventing foot and ankle orthopedic surgeons from doing cases. I’m almost tempted to say, let the AAOS fill all the 400 DPM positions with foot and ankle orthopedists so there will be a lot of great jobs available for DPMs in ortho groups.

Bret Ribotsky, DPM, Boca Raton, FL



From: Narmo L. Ortiz, Jr., DPM


After a few years of reading countless opinions, statements, and rebuttals in PM News about achieving parity for our profession, I am still amazed at the ongoing apparent "ignorance" of many of our colleagues on both sides of the debate. Has anyone ever taken the time to look at the history of osteopathic medicine in the United States and learn that DOs struggled for over 50 years to attain parity with allopathic medicine and when obtained, they kept their DO designation and principles? With all the progress and improvement in a DPM's education and training, why are we still fighting each other?


Like many of my colleagues, I work in a hospital system alongside MDs and DOs. We consult each other, collaborate with each other and respect each other's expertise in our chosen specialties. Yes, ladies and gentlemen, it is called a TEAM, and who benefits?: the PATIENT.


I applaud the APMA's efforts in responding to the misinformation provided by those who still seek to keep us on the sidelines, and in closing, with all due respect to some of the scholars and experienced colleagues (DPMs, MDs, and DOs alike) who still support such misinformation, I would hate to think that the real reason for this debacle and lack of unity to support the advancement of DPMs to parity (while maintaining our designation and principles) is to serve an egotistical and self-grandiose purpose.


Narmo L. Ortiz, Jr., DPM, Lakeland, FL.



From: Ken Hatch, DPM, Rahn Ravenell, DPM


There is a LOT of truth in this letter, as well as some misleading information.


Ken Hatch, DPM, Annapolis, MD


I've done the APMA eAdvocacy for both the passed House Bill and now the Senate Bill. What I find is that the stock letter is verbose, and the intent could get lost. I modified the letter to include a distinct rebuttal to the AAOS letter and highlighted the training of today's podiatrists. Is there a letter from ACFAS, ABFAS, and APMA that specifically outlines the training we receive?


If I read the AAOS' letter without knowledge of our training, I certainly would be hesitant to put a DPM on the same level as an MD if I believed they received their degree after "podiatry college and 0-3 years of residency training."


Rahn Ravenell, DPM, Mt. Pleasant, SC



From: Robert Scott Steinberg, DPM


First off, if someone is naive enough to believe the shoe salespersons, even if they are CPeds, then it's buyer beware. But, if the person then presents to your office with the same or worsening pain, you have the opportunity to show off your expertise. If the patient feels the store ripped them off, you can write them a letter stating why the device was improperly made and sold (dispensed). Your patient can then try to get a refund and, failing that, forward their complaint, with your letter, to their state's attorney general's office. Your state law may also be of help, so contact your state society.


One other thing, be a secret shopper, and find out exactly what the store is claiming and what they are doing. Record the encounter.


Robert Scott Steinberg, DPM