04/26/2018    Josh White, DPM, CPed

Employee Incentive Bonuses for Therapeutic Shoe Program

I’m glad this office is encouraged to fit more
patients with diabetes at risk for foot
ulceration with shoes covered by Medicare. There
has been a several year trend of fewer shoes paid
for by Medicare while the number of patients who
qualify has continued to increase. The good news
is that prepayment audits for diabetic shoes that
had been so common are no longer a Medicare
priority.

While bonus payments to employees performing shoe
fitting under the supervision of the DPM may seem
like a logical way to increase the number of
patients provided care, please be aware that “per
patient” compensation might attract enforcement
scrutiny by regulatory authorities as Medicare
anti-kickback rules, while allowing carve-outs
for employees, prohibit directly connecting pay
to what Medicare is billed for.

A suggestion is to tie other, less direct
performance indicators to productivity. Some
suggestions include:
• Number of shoes fit versus previous year (if
not increasing, something is amiss)
• Ratio of patients fit one year that are refit
the next (“Refit Rate”)
• Fit Rate (a measure of number of shoes
returned)
• Fitting target number of shoes based on number
of patients in the practice with Medicare and
diabetes.

Besides compensation, other important factors
that can significantly help practices to fit more
diabetic patients with shoes include:

• Communicate the attitude espoused by David
Armstrong that diabetic feet, free of ulceration,
should be seen as "in remission". A rigorous,
multilateral approach including proper shoe
fitting is essential for keeping ulceration and
the associated risk of morality at bay.
• While several people in the practice may be
involved with shoes fitting, make one person
ultimately accountable for achieving targets;
when more than one person in responsible, no one
is accountable.
• Ensure that the person responsible for the shoe
fitting program loves fitting shoes, is good at
it and has the time to fit as many patients as
are referred. People other than the doctor are
capable of doing a great job fitting shoes and so
the shoe fitter should not be the doctor.
• If the office is short staffed, appreciate that
fitting one pair of shoes per day earns enough to
pay for a full time person. If the practice has
patients with diabetes, it can afford the help
needed to fit shoes.
• Determine number of patients in the practice
with Medicare and diabetes and ensure that DPMs
perform a comprehensive diabetic foot exam on
each, at least once annually. Such an approach
can also satisfy MIPS Quality Measures 126 and
127 and may qualify for a 99213 E&M visit.
• Benchmark, based on the number of patients in
the practice with DM and Medicare, how many
should be fit with shoes; conservatively 75% of
patients will have a risk factor such as
decreased feeling, decreased circulation or a
hammertoe, to qualify. Report the number of
shoes dispensed each month to ensure that fitting
remains on track.
• Clearly define the process for evaluating
patients, selecting shoes, obtaining compliance
documentation, ordering shoes and appointing
fitting with assigned responsibilities and make
sure that is is “followed by all”.
• If referrals for fitting are “off-track” or
less than targeted, identify and discuss the
reasons and create permanent solutions.
• Update shoe samples and catalogs to ensure that
the office is offering patients shoe styles they
look forward to receiving each year.
• Communicate to patients the value of “wearing
shoes out”; ‘ shoes are intended to promote
walking and improve health.

Less than 10% of patients with diabetes and
Medicare who qualify for and would benefit from
shoes are fit each year. While many DPM offices
have stopped fitting shoes because of frustration
with Medicare compliance requirements, solutions
for streamlining the process are available. It’s
encouraging that many practices “get it” and are
fitting more shoes than ever and that the number
of amputation on patients under a comprehensive
plan of care have been reduced.

I encourage all offices to look at their
protocols to determine how they can better serve
their patients with diabetes and increase
recurring practice revenue.

Josh White, DPM, CPed, NY, NY

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