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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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