08/07/2013
RESPONSES / COMMENTS (MEDICAL LEGAL)
RE: Treating Homeless Patients (David Wolf, DPM)
From: Sloan Gordon, DPM
This is a very noble effort. I suspect that is why many of us became involved in medicine. I echo the letter of Dr. David Wolf and add this: we get called from the regular ER and Elder ER to see patients, some of whom are 'homeless' or without the ability to pay. We take care of them and do our best. We document this. In fact, our hospital has a department dedicated to try to get these folks Medicaid so they may have continued care.
I don't think [obviously not a legal opinion] you have to concern yourself about following up with labs, etc. Many of these patients are grateful to have any care. As podiatrists, I think we do a great job for them.
Sloan Gordon, DPM, Houston, TX, sgordondoc@sbcglobal.net
07/17/2013
RESPONSES / COMMENTS (MEDICAL LEGAL)
RE: Educating Employees About HIPAA (Michael Forman, DPM)
From: Raymond F Posa, MBA
I would like to add the following tips: Just having a sign in sheet of employees who attend your in-house training is usually not sufficient evidence of adequate training and the sign-in sheet can be considered a self-serving document and be excluded as proof of training.
I recommend the following: Have a formal printed outline of the HIPAA items being trained, or a power point slide deck on and keep a copy to demonstrate to an auditor the material being presented to the staff.
Second, have a written quiz on the material. You want to demonstrate that the staff have a comprehension of the material.
Finally, have all staff members sign an acknowledgement of training form. This is required by both the Privacy and Security rule, and instructions for this must be contained in both your privacy and security manuals.
This three-prong approach demonstrates proper training and an understanding of the HIPAA requirements. Also training must be done annually and with new hires within 90 days of being hired.
Raymond F Posa, MBA, Farmingdale, NJ, rposa@themantagroup.com
07/16/2013
RESPONSES / COMMENTS (MEDICAL LEGAL) - PART 2
RE: Compensation for Medical Report
From: David Gurvis, DPM
I also charge a flat beginning fee of $1,000. That will normally cover the basics to write a report. If I go over 2 hours, the charge is $500/per hour. I get my check in advance, having learned the "hard way" years ago.
If I am later asked to do a video deposition, the clock begins running again starting at $1,200. I have never had a problem getting paid.
David Gurvis, DPM, Avon, IN, egosumerus@aol.com
07/16/2013
RESPONSES / COMMENTS (MEDICAL LEGAL) - PART 1
RE: DVT Protocol
From: Zeeshan Husain, DPM
Here is the form that two of my local hospital systems use for DVT prophylaxis. The guidelines are based on the recommendations from the following articles:
Geerts, et al., Chest 133:381S-453S, 2008.
Seruya, et al., Plastics and Reconstructive Surgery 122(6):17 01-08, 2008.
Hatel, et al., Plastics and Reconstructive Surgery 122(1): 269-79, 2008.
The form evaluates the patient for risk factors and...
Editor's note: Dr. Husain's extended-length letter can be read here.
07/13/2013
RESPONSES / COMMENTS (MEDICAL LEGAL)
RE: Educating Employees About HIPAA
I think everyone should be reminded that HIPAA requires that all entities educate their employees about HIPAA. Our method is a yearly meeting where we discuss HIPAA rules. Be sure to have everyone in attendance sign in, as documentation is paramount.
Michael Forman, DPM, Cleveland, OH, im4man@aol.com
06/11/2013
RESPONSES / COMMENTS (MEDICAL LEGAL)
RE: AFO Fabrication Licensure? (Olga Luepschen, DPM)
From: Paul Kesselman, DPM
I assume the licensure you refer to has to do with orthotists/pedorthists and their scopes of practice, and not municipal or other commercial licensure issues. Some states require the entity interfacing with the patient to be licensed. However, that does not appear to be your scenario. Since no employee or official from the lab ever interfaces with the patient, you are the only entity subject to licensure.
Paul Kesselman, DPM, Woodside, NY, drkesselmandpm1@hotmail.com
06/03/2013
RESPONSES / COMMENTS (MEDICAL LEGAL)
From: Bill Deutsch, DPM, Sal J. Galluzzo, DPM
Like a jealous lover, third-party is calling your patient to whisper sour grapes in their ear. My advice would be to make patients aware that they may from time to time be contacted by third party payers. It shouldn't be a surprise or a shock, and that nothing untoward may be surmised if this should happen. Inform your patients that like any service company, third party payers may call to ensure they're satisfied with your service, and it's standard quality control measures. A sign or handout should suffice.
Hey wise up doctor. If you're doing the right thing and billing for what you really do and document, WHAT are you worried about? Your patients "have your back" if it comes down to it. Medicare will do whatever they can/have to do to SAVE and CUT reimbursements. Let's face it - It's going to get tougher as Medicare gets tighter. Put on your rain gear - we're gonna have a BIG STORM!
05/31/2013
RESPONSES / COMMENTS (MEDICAL LEGAL)
RE: Documenting Radiological Findings (George Stephen Gill, DPM, MBA)
From: Kenneth Meisler, DPM
Podiatry specific or not, any good EHR should have a complete template for radiographic findings. I am in the implementation phase with my new EHR, Pod-Practice from 20/20, and one thing that I found exciting was the radiograph report. It is in an easy check-off format, you can document both extremities with different findings from a variety of choices, or add your own. You can add the template to an existing note by simply typing the word "x-ray", or save it as a separate attachment altogether as Dr. Gill recommended.
See an example of a radiograph report below.
X-ray Report...
Disclosure: I am a consultant for 20/20 Imaging
Editor's note: Dr. Meisler's extended-length letter can be read here.
05/30/2013
RESPONSES / COMMENTS (MEDICAL LEGAL)
RE: Documenting Radiological Findings (Michael G. Warshaw, DPM)
From: George Stephen Gill, DPM, MBA
Thank you Dr. Warshaw for your opinion and comment. Your post seems to validate my original statement: "There is no basic agreement or template on what constitutes an adequate and/or appropriate radiographic record entry ...for medical review purposes." If we as a profession can agree, then having a "standard radiographic outline" to advance for third-party peer review could negate some subjective opinions and negative actions.
George Stephen Gill, DPM, MBA, Denver, CO, georgestephengill@gmail.com
05/27/2013
RESPONSES / COMMENTS (MEDICAL LEGAL)
RE: Documenting Radiological Findings (Name Withheld)
From: Theresa Hughes, DPM
This is the template that I use. This was developed by my coding department as a template to hit all the required material.
DICTATING PHYSICIAN:
HISTORY:
EXAM:
QUALITY: (CLEAR, BLURRY)
FINDINGS:
IMPRESSION:
FURTHER STUDIES:
Sign, date and time
Theresa Hughes, DPM, Galesburg, IL, Theresa.M.Hughes@osfhealthcare.org
05/25/2013
RESPONSES / COMMENTS (MEDICAL LEGAL)
RE: Documenting Radiological Findings (Name Withheld)
From: George Stephen Gill, DPM, MBA
It would seem reasonable that this profession could adopt /standardize a basic radiological template that would facilitate a check-off process that would adequately and appropriately document pertinent radiographic findings satisfactory to a review process. The form might contain a summary conclusion: Additional pertinent findings: an inserted comment (summary) that would delineate unusual or exceptional findings (conclusions) and their relevancy to the Dx/Tx plan.
George Stephen Gill, DPM, MBA, Denver, CO, georgestephengill@gmail.com
05/23/2013
RESPONSES / COMMENTS (MEDICAL LEGAL)
RE: Documenting Radiological Findings (Name Withheld)
From: David Secord, DPM
About 10 years ago, I was first informed that this needed to be done as a separate note from the E/M note. Although it is a pain to do all this documentation, it did come in handy when an insurance company wanted a Roentgenographic report on a patient before approving an MRI or computed tomography (or a surgical procedure).
David Secord, DPM, Corpus Christi, TX, ledocdave@hotmail.com
05/07/2013
RESPONSES / COMMENTS (MEDICAL LEGAL)
RE: Grounds for Patient Dismissal (Charles Morelli, DPM)
From: Howard R. Fox, DPM
As our editor pointed out, this issue is between the anesthesiologist and your patient, not you. I don’t think you can refuse to perform additional surgery because your patient stiffed the anesthesiologist, but you can warn your patient that when you book a second surgery, it might be impossible to get an anesthesiologist to agree to involve themselves with your patient under the circumstances. While it might be entirely possible to perform your subsequent surgery with only local anesthesia, it would be your call to decide whether that’s in the patient’s best interest. If he’s gonna squirm around on the table or work himself into a compromised state of health because he’s not sedated, you can certainly insist on doing your surgery with an anesthesiologist present. If you can’t get one, then you’re unable to do the surgery.
You may want to share a story I had with that anesthesiologist. Several years ago, the same thing happened to me where the patient pocketed insurance reimbursement and wasn’t paying me. I called the patient and told him at 4:30 PM today, I’m making a call to the IRS to inform them of this unreported taxable income he received which will almost certainly result in an audit. I received the entire amount in cash that very day.
Howard R. Fox, DPM, Staten Island, NY, fox.howard@gmail.com
05/04/2013
RESPONSES / COMMENTS (MEDICAL LEGAL)
RE: Patients' Requests for X-Rays (Charles Morelli, DPM)
From: Michael L. Brody, DPM
To address Dr. Morelli’s question regarding sending digital x-rays via unsecured email, the answer is "yes," it is a violation. There are 18 elements that constitute identifiable personal information. If any one of these is present and the email is unsecure, it is a violation. One of the elements is a person’s email address.
It may sound like a very technical issue, but the law is the law; at a thousand dollars a pop for a violation and opening the door for further scrutiny, just get a secure email service such as Zix mail (zixcorp.com).
Raymond F. Posa, MBA, Farmingdale, NJ, rposa@themantagroup.com
Regarding the post of using a secure email service such as Zix: The new HIPAA Omnibus Law which was published on January 26, became effective on March 26, and becomes mandatory on September 23 has some very strong language in it regarding sharing patient information (even encrypted patient information) with other entities such as Zix. You MUST HAVE a valid up-to-date Business Associate Agreement with service providers, such as Zix, that provide routing and storage of your e-PHI (Electronic Protected Health Information). Failure to have this document is a clear violation of the new HIPAA Omnibus Act.
Michael L. Brody, DPM, Commack, NY, mbrody@tldsystems.com
05/03/2013
RESPONSES / COMMENTS (MEDICAL LEGAL) -PART 3
RE: Patients' Requests for X-Rays (Michael Brody, DPM)
From: Charles Morelli DPM
Dr. Brody stated that emailing copies of x-rays is a potential HIPAA violation. Whenever I do this, and do it with some degree of regularity, the digital image that is sent to the patient (or to anyone for that matter) has no information or demographics printed on it. There is absolutely no way to identify who the x-ray would belong to. Does this qualify as a potential HIPAA violation?
Charles Morelli, DPM, Mamaroneck, NY, podiodoc@gmail.com
05/03/2013
RESPONSES / COMMENTS (MEDICAL LEGAL) -PART 1
RE: Hired Gun Testimony of a Radiologist (Charles Lombardi, DPM)
From: Lawrence J. Kansky, DPM, JD
Dr. Glenn Schwartz did nothing wrong. He was not a hired gun because the transcript reveals that this was Dr. Schwartz's first court appearance, he was a subsequent treater, and he was paid a reasonable $4,000 for his time. Dr. Schwartz's testimony was consistent with his written report of 2006. He simply supplemented what he believed the "post-operative changes" were on the MRI. We all know that a nerve can be partially cut in the healing phase, or be damaged, mangled, or compressed while still being "intact".
A jury determines whether there is podiatric negligence, and not just a common unavoidable post-operative complication, based largely on the testimony from the podiatric expert(s) regarding causation and departure from the standard of care. Dr. Schwartz admitted multiple times that he did not know what surgical procedures were performed, so the jury only gleaned from him that the nerve at issue was not normal.
Calling Dr. Glenn Schwartz as a witness should have been somewhat anticipated by Dr. Lombardi's defense team because all potential witnesses, which usually includes all treating doctors, are listed with the court before trial. I thank Dr. Lombardi for sharing his upsetting and stressful experience with us, and congratulate him on his win.
Lawrence J. Kansky, DPM, JD, Wilkes-Barre, PA, Larry.Kansky@gmail.com
05/02/2013
RESPONSES / COMMENTS (MEDICAL LEGAL) -PART 2
RE: Wireless Printers and HIPAA (Elliot Udell, DPM)
From: Marc Garfield, DPM
Your wireless network needs to be encrypted and password-protected. I switched to the Konica Minolta 5650EN seven months ago, after two HP printers could not handle the workload. Make sure the printer that you get has enough RAM (about 128 MB) to handle commercial use, and that it sips ink carefully. The Konica Minolta has been faultless and the starter cartridge has lasted several months. The full (@$220)cartridge last 6-12 months. I used to go through one to two HP laser toner cartridges per month at about $80 a piece. So in seven months, I have spent less on the printer and Ink than I would have spent on toner alone with the HPs that I retired.
Marc Garfield, DPM, Williamsburg, VA, mgarfield1@cox.net
05/02/2013
RESPONSES / COMMENTS (MEDICAL LEGAL) -PART 1
RE: Hired Gun Testimony of a Radiologist
From: Charles Lombardi, DPM
I just concluded a malpractice trial that took 7 weeks of my life. I will be posting the transcripts on PM News. I have attached a transcript of the testimony of Dr. Glenn Schwartz who works for Empire Imaging/Long Island Radiology. The claim against me was that I cut the medial plantar nerve while doing a removal of an os trigonum from the lateral side. The plaintiff sued me, the anesthesiologist, and all the residents and associates. He claimed that he had chronic pain everywhere. He even had subsequent surgery by a neurosurgeon.
Dr. Schwartz read a post-operative MRI in 2006 and said that except for post-operative edema, all structures were intact. That was the only "contact" with the patient. In the middle of the trial, when the plaintiff's lawyer realized he might be losing, he contacted Dr. Schwartz and paid him to come in as a subsequent treating doctor. Dr. Schwartz now says there was damage around the nerve (five years later) for money! What makes this worse is that Dr. Schwartz sat on the medical board with me for five years at Flushing hospital.
I ask you to read this transcript (start at page 40) and see if you have a concern about referring your patients to a radiology group that will later come back and change their report to hurt you.
Charles Lombardi, DPM, Bayside, NY, ChazDPM@aol.com
05/01/2013
RESPONSES / COMMENTS (MEDICAL LEGAL) - PART 1B
RE: Wireless Printers and HIPAA (Elliot Udell, DPM)
From: Al Musella, DPM
Dr. Udell brings up an important point. There are free tools available that allow anyone to scan your wireless network. If your wireless network doesn't have encryption, anyone can have all of your passwords and access to everything on your network within minutes.
To prevent that, you need to use encryption. The older style was called WEP. Older computers can only use this method - but it is an option on...
Editor's note: Dr. Musella's extended-length letter can be read here.
05/01/2013
RESPONSES / COMMENTS (MEDICAL LEGAL) -PART 2
RE: Patients' Requests for X-Rays (Don Blum, DPM, JD)
From: Michael J. Hodos, DPM, Michael L. Brody, DPM
Prior to getting a digital x-ray system, I would do the same; take a digital photograph of the x-rays and send it to the patient.
Whenever I send sensitive information over the Internet, I always encrypt it. I typically send a PDF file that is encrypted with the patient's SSN. It is free, something that the patient knows, their PCP would know, etc., and allows for safe transmission. I do the same thing when I send information to my accountant, as he has my SSN already as well.
Michael J. Hodos, DPM, Wake Forest, NC, mike@mikehodos.
Dr. Blum indicates that he emails copies of x rays to patients. I strongly recommend against this practice as email is not secure and this is a potential HIPAA violation.
Michael L. Brody, DPM, Commack, NY, mbrody@tldsystems.com
05/01/2013
RESPONSES / COMMENTS (MEDICAL LEGAL) -PART 1A
RE: Wireless Printers and HIPAA (Elliot Udell, DPM)
From: Michael L. Brody, DPM
As Barry Block indicated, most wireless printers have a 'wired' network option. The issue with HIPAA and wireless printers is the same for any and all wireless devices, and that is security. If you can avoid going wireless and use only a wired network, it has a higher degree of security. If you intend to utilize wireless networking in your practice, you want to ensure that you have the best possible security on that wireless network.
When using wireless communications, I recommend that you always utilize WPA-2 or better encryption, turn on MAC filtering, and monitor your wireless access points for attempted "break-ins" to your network. It is best to utilize the services of a network professional when deploying wireless networks. No matter if you have a wired, wireless, or a hybrid network (Part wired, part wireless), you want to have a good firewall and good security for your entire network to protect the network from attacks.
Michael L. Brody, DPM, Commack, NY, mbrody@tldsystems.com
04/29/2013
RESPONSES / COMMENTS (MEDICAL LEGAL) -PART 1
RE: Patients' Requests for X-Rays (Joseph Borreggine, DPM)
From: Robert Wunderlich, DPM
In my experience, most hospitals and radiology groups that perform radiographs using a digital system are happy to provide a copy of the images on a CD-ROM (which also contains a stripped-down version of the software to view the images). New patients will often bring a copy of the CD with them to the office. If they don't, we've had no problem requesting a copy of the CD. Typically, they'll deliver it the same day via courier.
Robert Wunderlich, DPM, San Antonio, TX, rwunder@gmail.com
04/27/2013
RESPONSES / COMMENTS (MEDICAL LEGAL) - PART 1
RE: Patients' Requests for X-Rays (Joseph Borreggine, DPM)
From: Michael Brody, DPM
You should NEVER email patient information. It is a HIPAA violation.
Personally Identifiable Information (PII) must be protected by your practice. Personally Identifiable Information is any information that can be used to distinguish or trace an individual's identity. This includes:
Full Name
Maiden Name...
Editor's note: Dr. Brody's extended-length letter can be read here.
04/23/2013
RESPONSES / COMMENTS (MEDICAL LEGAL)
RE: Accommodating Disabled Patients (Name Withheld, NJ)
From: Stephen Musser, DPM
Check with an attorney. Although there are some exemptions, you will more than likely have to bring your building up to ADA standards.
Stephen Musser, DPM, Cleveland, OH, ly2drmusser@gmail.com
04/20/2013
RESPONSES / COMMENTS (MEDICAL LEGAL)
RE: Accommodating Disabled Patients (Name Withheld NJ)
From: Steven Finer, DPM
I have been on the second floor of a building since 1978. I never would have considered it if there was no elevator. Over the years, you will lose 10% of potential patients. Would you put in a tiny door blocking extra tall or obese people?
Steven Finer, DPM, Philadephia, PA, thefiners@yahoo.com
