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RE: Obtaining Reports from Uncooperative Specialists

From: Elliot Udell, DPM

In this new medical environment where physician's offices are being bought up by corporations and hospitals, doctors are becoming salaried employees. One of the problems we are facing is that many  specialists who were eager to send me written reports so that I would continue to send them new patients, no longer care if I do or don't. One infectious disease group in my area that used to chase after every referral now pre-screens potential patients, and someone on staff decides whether they will even see a new patient.

Needless to say, if an infectious disease doctor or vascular specialist does not communicate with me about a mutual patient, I am placed in medical-legal risk. Even worse, the patients often call me to ask if I received a report, and I have to keep saying "no." In one case, I called an office supervisor and "read him the riot act" and the doctor called back letting me know that she has difficulty with the new EMR system and can't send written notes. In other cases, even after calling, I have gotten no response.

The seemingly simple solution is to find different specialists; however, every day more and more specialty and general medical practices are being gobbled up by corporations. The doctors are not paid well, are overworked and not inclined to be responsive. Has anyone else encountered this problem?

Elliot Udell, DPM, Hicksville, NY,

Other messages in this thread:



RE: Using an Orange Light to Better Visualize Lesions

From: Daniel Chaskin, DPM


Skin cancer on the feet can result in death. In some patients, a parallel ridge pattern on the dermatoglyphic areas of the feet indicates a high probability of skin cancer. Sometimes, examination under a polarized or non-polarized white light just might not provide a clear diagnosis.


I discovered that an orange light may be helpful in distinguishing between the parallel furrow and parallel ridge patterns. I believe other colors might also give similar, if not improved, ability to give a more accurate diagnosis. 


Daniel Chaskin, DPM, Ridgewood, NY



From: Michael L. Brody, DPM


Dr. Steinhauser is 100% correct in the reason for all of the chart reviews. The term is known as "Risk Adjustment", the amount of money the insurance company receives is modified by the risk status of the patient population. In chart reviews, they are looking for medical conditions that were not reported as an ICD-10 code on the bill.


Michael L. Brody, DPM, Commack, NY



RE: Change in ABFAS Rules Prevents Recertification

From: Michael Z. Metzger, DPM


I received my (ABPS) certification in 1992. I was required to be re-certified and thought I had done so in 2002. I passed the exam and then learned that under the rules, I could not be recertified unless I submitted cases.  Because I had changed my practice and was not doing surgery back then, I was not be able to get my new certification. 


I wrote to the board officers and never heard anything. I still have no idea how they had the authority to just change the requirements retroactively. The fact that I got my original certification under certain requirements and rules made no difference. By the way, they have since dropped the requirements for cases, but I was still “uncertifiable”. 


Michael Z. Metzger, DPM, Houston, TX



RE: Unreasonable Chart Reviews 

From: Dave Williams, DPM, Gian Steinhauser, DPM


I have seen a big increase in chart requests as well. I submitted 30+ just last week. Dr. Rettig posted, “I, and most doctors, charge the plan for copying the charts and collect enough to make it worthwhile.” I didn’t even know that was an option. What is the process and how much do you charge?


Dave Williams, DPM, El Paso, TX


Our office has also been getting multiple requests for 50-100 charts at one time as well. We pride ourselves on having excellent documentation and an EHR system that makes chart retrieval “easy”, so we don’t worry about the chart reviews. In fact, we welcome them, as we charge the insurance companies $25/chart, to cover the labor and printing costs. Requests for insurance payment refunds are few and far between at our office.


I was informed by an industry insider that the reason the insurance companies are requesting these charts is ...


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



From: Richard Rettig, DPM


Dr. Hofaker, I think you misunderstand the situation. Medicare Advantage plans get paid by CMS on a capitation basis per client. They get a higher payment if the patient has a lot of co-morbidities. They know a doctor may send in claims and place a single diagnosis for payment, but there may be many more diagnoses within the note that would allow them to collect more from CMS. So they audit charts to find those diagnoses. It has absolutely nothing to do with your care; you personally are not being audited. They would have no reason to get back to you. Further, I  and most doctors charge the plan for copying the charts and collect enough to make it worthwhile. I look forward to these requests!


Richard Rettig, DPM, Philadelphia, PA



RE: Unreasonable Chart Reviews

From: Rich Hofacker, DPM


I am just wondering about all of these insurance company "chart review" requests and what other pods are doing about it. Medicare and Medicaid do not routinely request them. However, it all started years ago with Medicare Advantage Plan insurance companies. The insurance companies were requesting one or two charts at a time. Now we are seeing 50-70 chart requests at a time. The insurance companies never get back to you in regard to what you are doing right or wrong. They just request more and more charts. I am perplexed by all of this, primarily because I just no longer have the time to reply to all of these frivolous requests that have gone from a yearly time frame to a monthly time frame.


Rich Hofacker, DPM. Akron, OH



RE: The Origins of Surgical Residencies

From: Rick Harris III, DPM


Halsted. Who cares? Well perhaps any physician who has trained at a surgical residency program. Dr. William Halsted played a vital role in the rise of surgery as a specialty as he helped to establish the first American surgical residency at The Johns Hopkins Hospital in 1889.


After attaining his medical degree from the Columbia University College of Physicians & Surgeons, Dr. Halsted spent 2 years training in Austria and Germany. Through his training in Europe, he became acquainted with the German system of graduate surgical education. He brought this paradigm to the United States thus having a profound impact on the American surgical residency system. Dr. Halsted described the purpose of his residency program as follows: “We need a system, and we shall surely have it, which will produce not only surgeons, but surgeons of the highest type, men and women who will stimulate the first youths of our country to study surgery and to devote their energy and their lives to raising the standard of surgical science.” Tip of the scrub cap to the Father of American Surgery for his contributions over a century ago that helped to get us where we are today. 


And of course, a tip of the cap to Dr. Earl Kaplan, for opening Civic Hospital in 1956, the first podiatric teaching hospital in the United States. Lastly, a tip of the cap to all podiatric surgery residency attendings as they continue to train the next generation of foot and ankle surgeons. 


Rick Harris III, DPM, Jacksonville, FL



RE: Florida’s New Law on Controlled Substance Prescribing

From: George Jacobson, DPM


H B 21, signed into law by Gov. Rick Scott on March 19, 2018, imposes a number of legal requirements on healthcare practitioners who prescribe controlled substances. A prescriber must consult "the database" to review a patient's controlled substance dispensing history before prescribing or dispensing a controlled substance. This requirement applies to all controlled substances, not just opioids. There is now a substance prescribing continued education requirement for each physician to be completed by Jan 31, 2019, and then prior to each subsequent licensure renewal. Details of this new law are outlined in this article:


George Jacobson, DPM, Hollywood, FL  



From: Joseph Borreggine, DPM


I do not know if this individual is an outlier or is the typical norm for an ABFAS candidate, but it should raise eyebrows for the entire profession if this issue is a frequent problem. The facts are plain and simple... the cost and time involved to reach this pinnacle of certification may be in excess based on the supposed high quality education and training that every podiatric student receives prior to this achievement.


It is my understanding that podiatry is equal to allopathic and osteopathic medicine less a few educational courses and post-graduate rotations. And as a specialty requiring all DPMs to be trained as “foot and surgeons”, passing of said exam should be a piece of cake. Alas, it is not. The pass rate the first time a candidate takes this exam is much less than 50%. 


The second or third time it is taken, the results are appreciably higher, but these multiple attempts to pass an exam which should reflect the candidate’s aptitude is unnecessary. Our orthopedic colleagues seemingly take a similar exam and have a much higher first pass rate as compared to our comparative board exam. 


I find this disheartening in light of the fact that podiatry is and has been fighting for parity. This concern from this ABFAS Diplomate is valid and should be investigated. If not, then it should fe explained so that prospective ABFAS candidates can understand more thoroughly how this process really works.


Joseph Borreggine, DPM, Charleston, IL



From: Don Peacock, DPM


With ABFAS board certification discussions, we sometimes miss a very important point. The boards give credence to our surgical achievements and that’s all. Our greatest achievements will be in helping people, not in ABFAS certification. Lacking certification will not prevent a good podiatrist from making a great living. The huge effort to obtain and remain board-certified for the purpose of hospital privileges is becoming less important as well. I perform most of my surgeries in the office setting where hospital privileges or board certification is optional. 


Whether we're board-certified or not, our surgical income means little with respect to our financial health. The bulk of reimbursement for a successful foot surgeon remains non-surgical. With current cuts in procedure-based and fee-for-service models, it would behoove all of us to move more surgeries to the office setting where reimbursement is better and turnover quicker.


In the overall scheme of things, board certification is not as important as being a good doctor, having patients that like you, and doing a good job at treating those patients. That is how you will be successful. The board certification is the icing on the cake. It is not the cake.


Don Peacock, DPM, Whiteville, NC



From: Marshall Feldman, DPM


Are you kidding? You should thank your lucky stars that you can even sit for the Board. Because of the men and women that came before you, you are now able to provide the most  comprehensive treatment of foot and ankle disorders in our country. I am not going to waste my time by describing how practicing our profession was like prior to the advent of ABFAS.  Nor will I waste my time to explain how other medical professionals perceived our profession, again prior to the Board's creation.  However, I will say that you should count your lucky stars that the leaders of our profession determined that it was paramount to create a substantial and esteemed panel that would properly ascertain the qualifications of a potential applicant.


To that end, yes the cost is not cheap in order to be able to complete the required certificate. Yes, you were not able to buy into an out-patient surgical center of your choice nor attain hospital staff privileges or even retain them due to the fact that you were not "boarded". You should get down on your knees in order to thank those who came before you and opened the doors for you to enter these institutions with the knowledge and I hope ability that you have attained.


On another note, why the heck does it matter that the ABFAS headquarters are in California?


Marshall Feldman, DPM, Rahway, NJ



From: Name Withheld 2


Much like Name Withheld, I also wish to remain anonymous for fear of incurring the wrath of ABFAS, which carries far too much power over our career progression. I failed the case review for RRA this year and the justification provided was ridiculous, arbitrary, and in just about every case, flat out wrong. This suggests to me that my cases weren't actually reviewed with any degree of scrutiny. Unfortunately, we have no recourse other than "you still have 2 more years of eligibility so try again next year." 


It's well known among my colleagues that it's a scam and you'll pass in your 6th or 7th year. If ABFAS was concerned about quality of its diplomates, the case review would be...


Editor's note: Name Withheld 2's extended-length letter can be read here.



From: Brant McCartan DPM, MBA, MS


Great MIS recap and points. I am “the younger DPM”, finishing a 3-year residency in 2013. To answer some of your questions, I have noticed about fifty older generation doctors who have never given up MIS - and have been doing so for 30+ years. They are anxious to teach and happy that MIS has a growing acceptance, despite being more so internationally as opposed to locally. I believe the appearance of a resurgence is more due to the industry “getting in the game” (nominally Wright and Trilliant; maybe more companies making screws specifically for MIS style bunion correction).


This is interesting because the originators of the MIS bunion-style surgeries rarely use any hardware, if any, in their procedures! But now that industry is involved, it instantly becomes interesting, and a more acceptable, viable option or technique. Show me the percentages of established lecturers or board members in any medical organization who consult for at least one company, likely more. Money talks.


Brant McCartan DPM, MBA, MS



From: Steven Finer, DPM


When I graduated from PCPM in 1976, I was then fortunate to do a residency and join a local hospital. We were trained to do everything open and follow orthopedic thinking. I bought a small practice from an older practitioner. It was obvious that he was doing in-office MIS after taking a weekend course. The x-ray results were uniformly poor and I found a lot of letters from angry patients and investigations from insurance companies. It was clear to me he had little understanding of basic operative procedures, blood chemistry, and standard operative protocol. I steered clear of all of this and used the hospital only. Now years later, with new techniques, changes in insurance, and the blessing of orthopedists doing essentially the same procedures, MIS has found a place in the podiatry world.  


Steven Finer, DPM, Philadelphia, PA



From: Elliot Udell, DPM


Having witnessed the origins of MIS and the political squabbles within the profession, I now have a broader perspective on it. Yes, there were two schools back then. There were the "open" surgeons and there were those who took the late Dr.  Ed Probber’s one-week course on how to do MIS (in the back of his Long Island office). The training was often supplemented by learning at other doctors offices and at MIS conventions.


There were conflicts and a lot of name calling. Some of the criticisms of MIS were valid and some were purely political. At that time, podiatry was striving to be part of the medical/surgical establishment and MD surgeons did not know from MIS. Today, things are different. MD surgeons are gravitating toward minimal incisional techniques. They do spine surgery, knee operations, gall bladder removals, and hernia repairs using very small incisions. The healing time is reduced. Hence, there should no longer be a need for two schools of thought in 2018. It’s time for foot surgeons to learn open and minimal incisional techniques and choose the best one for each and every patient who needs foot surgery. Let’s leave the politics of it back in the 1970s.


Elliot Udell, DPM, Hicksville, NY



From: Burton Jay Katzen, DPM


The answers to Dr. Borreggine's questions are long and complicated ones dating back approximately 60 years. Minimally invasive surgery is now the standard of care in many countries throughout the world. However, I can say that resurgence of MIS in the United States can be traced, in no small part, to the exceptional outcomes our surgeons are seeing. This includes less patient downtime and the maximum use of the surgeon’s time and the ability to perform many of our procedures in an office setting or an outpatient ambulatory surgical center.


I believe that the future of MIS lies in the ability to teach the procedures in the schools and the residency programs. I am happy to note that the next Academy Of Minimally Invasive Foot and Ankle Surgery LSU lecture cadaver seminar to be held in New Orleans on May 31, June 1, and June 2 will include several residents from programs throughout the United States.


Burton Jay Katzen, DPM, Temple Hills, MD



RE: NJ to Monitor Gabapentin Prescriptions

From: Allen Jacobs, DPM


I know a lot of docs who decreased scripts for narcotics and began using gabapentin. Now this: 


Dear Prescriber, 


Effective May 7, 2018, the New Jersey Division of Consumer Affairs adopted amendments to the New Jersey Prescription Monitoring Program (NJPMP) rules at N.J.A.C. 13:45A to require New Jersey licensed pharmacies and registered out-of-State pharmacies to electronically transmit information to the Division about prescriptions dispensed for gabapentin. The recognition of gabapentin as a “drug of concern” stems from national prescription and overdose data. New Jersey is joining a growing list of states who have already begun to monitor gabapentin use, including those that have scheduled the medication at the state level. 


Studies have shown that gabapentin prescribing in the United States has increased...


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



From: Kim Antol


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Kim Antol, Sigma Digital X-Ray



RE: Absurd Repeat Fingerprinting Requirement

From: George Jacobson, DPM


I got fingerprinted five years ago as a requirement for Medicaid participation. I don't know if this is just in Florida or a federal requirement. We have a renewal  application and were told I have to get fingerprinted again. Did my fingerprints change? This is an absurd waste of my time. There aren't many places that do this that can directly send the fingerprints electronically. I think I spent around $150 last time. I hate stupid government requirements like this. Do government employees, congressmen, senators, and their staffs have to get fingerprinted every five years? I doubt it. When they start fingerprinting lawyers every five years perhaps it won't bother me as much. 


George Jacobson, DPM, Hollywood, FL 



From: Bret Ribotsky, DPM


I have used Tsheets for years with a few service employees. It geotags them, and lets you track them while on the job. It runs via their smart phones and works directly with Quickbooks payroll.  


Bret Ribotsky, DPM, Boca Raton, FL



RE: The Importance of Examining Legs 

From: Robert D. Phillips, DPM


I would like to commend the thoughtful letters written by Dr. Forman (4/14/18), Dr. Silver (4/18/18), and Dr. Jacobs (4/16/18). All bring to the fore the important facts that diabetes not only has a negative effect on all the systems in the foot, but that decrease in the utilization of the foot also accelerates the impact of the disease on the other body systems. 


Certainly, the main goal of any podiatrist treating the diabetic patient is to increase the activity level of the patient. Many years ago, I heard Dr. Root talk about no longer thinking of geriatric foot care as trimming calluses and nails and moisturizing the skin. Instead he stated that...


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



From: Bill Beaton, DPM


I would like to comment on Dr. Richard Simmons' post in regard to "non-medically licensed" personnel performing routine foot care and that procedure is billed as if the DPM personally performed the procedure. In Florida, it is against the Florida Podiatry Practice Act for anyone not licensed to perform any procedure that falls under the definition of the Practice of Podiatry.


Florida Statutes 461.003(5) states that "Practice of podiatric medicine" means the diagnosis or medical, surgical, palliative, and mechanical treeatment of ailments of the human foot and leg. The surgical treatment of ailments of the human foot and leg shall be limited to that part below the anterior tibial tubercle.


In my opinion, anyone other than a licensed podiatrist providing palliative foot care or a podiatrist that is supervising a non-medically licensed person is in violation of the Florida Podiatry Statutes and subject to penalties under Statute 461.012(2)(d).


Bill Beaton, DPM, Saint Petersburg, FL



From: Thomas Silver, DPM


I have tons of patients sent to me for "routine care" from large managed care clinics in my area. I often hear from these patients that they were seen by the podiatrists in their clinic and told by them, "I'm a surgeon. I don't trim toenails or calluses!" and that they often don't even look at their feet. They refer them out to the few clinics in my area (population >1 million) that do "routine care". 


In most all cases, I do a full lower extremity exam for these "routine care" patients. Many of the elderly have had knee or hip replacements, so I routinely measure for leg-length discrepancies, excessive pronation, collapsing or collapsed medial column, and I have them stand and walk. As a result, we fit...


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



From: Richard A. Simmons, DPM


Dr. Forman wrote: “I received notification from Medicare that 33% of my visits submitted included an E/M charge. I was told it was above the average.” To me, there are two issues here: 1) do you really want to go toe-to-toe with Medicare defending your E&Ms and 2) I am surprised that 33% is above average. I know that some doctors will challenge Medicare personally and spend a lot of time and effort defending their claims. If your office is equipped to handle this, then go for it. The 33% number seems low and may be something that APMA could look into. 


That said, there may be a lot of practices where “non-medically licensed” personnel are trimming toenails, corns, and calluses, and these offices may simply have a high turnover of procedures without examinations. On a side note, if a PA (physican assistant) or NP (registered nurse practitioner) submits a bill to Medicare, it is paid at a lower fee profile than if submitted by an MD, DO, or DPM; however, when “non-medically licensed” personnel perform routine foot care, that procedure is billed as if the DPM personally performed the procedure. Even though Dr. Forman may be practicing good medicine, it appears that the numbers may simply be against him.


Richard A. Simmons, DPM, Rockledge, FL



From: Lawrence J. Kansky, DPM, JD


As a criminal defense attorney, I have been involved in many felony theft cases such as the one written about by Name Withheld (MA) podiatrist. First, you did not make a mistake in agreeing with the district attorney to dismiss your employee's criminal charges in exchange for full restitution of the stolen $13,000  (In Pennsylvania this is called a "586" which is the PA Criminal Code Rule number that allows for Court dismissal upon satisfaction or agreement of the parties). If your employee became a convicted felon, you would likely have had no chance of getting your stolen money back, because in our judicial system, convicted felons lose just about everything.


In my PA cases, when a criminal defendant breaches the restitution part of their agreement, the victim usually contacts the district attorney, the criminal charges are immediately re-instated, and a warrant is issued for the defendant's arrest. The case then starts all over again, and the defendant cannot claim a due process right violation for lack of a speedy trial. Your state, (MA) is likely very similar to PA, so contact your district attorney as soon as possible.


You are not out of luck just yet, because many times after a defendant is re-arrested, the restitution money magically appears and the victim is quickly paid. Good people sometimes make bad mistakes for a variety of reasons, so I commend you for giving your employee at least a chance for a better life.


Lawrence J. Kansky, DPM, JD, Kingston, PA
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