|
|
|
|
|
Search
10/16/2013
RESPONSES/COMMENTS (MEDICAL/LEGAL)
RE: Routine Blood Work for Peripheral Neuropathy?
From: Tip Sullivan, DPM
The following are recommended by the American Academy of Neurology (AAN) as blood tests to identify the etiology of a diagnosis of peripheral neuropathy. The AAN gave fairly good data supporting these tests: -CBC -Arthritis Panel-RA latex, ANA, Uric Acid, SED rate -Complete metabolic panel -Hgb-A1c -serum protein immunofixation electrophoresis -B12 -B12 metabolites (methylmalonic acid/ homocystine) -TSH -Lyme Ab-RPR
According to the local lab I have used for years, the bill for these tests comes to approximately $3,600. I was wondering if anyone else believes this is crazy? There is some data suggesting that this is not justifiable in diabetics due to the likelihood of diabetes as the etiology. When patients come in with symptoms of a peripheral neuropathy with no obvious previously diagnosed medical, physical, or family history cause, what tests do you order? What if a patient came in with symptoms and you did not run a Lyme Ab ($630) and never found out that three years ago, the patient had symptoms of the flu and a mild rash after a camping trip in Maine (which he doesn't even remember)? You missed the diagnosis because you didn't follow the “guidelines” – Is there legal liability?
Other messages in this thread:
07/05/2024
RESPONSES/COMMENTS (MEDICAL/LEGAL) - PART 1B
From: Name Withheld (FL)
Name Withheld, I commend you for the way you will be handling a difficult situation. This was an honest mistake on your part, and you are trying to remedy the situation. The most important advice I would give you is to contact a medical consultant to guide you along this process. Hopefully, you are with a malpractice company that provides you with legal defense. If so, they will talk you through the process of reporting these errors to insurance companies. Several years ago, I had a circumstance where I misinterpreted the regulation of taking x-rays in my office. I thought the rules stated that as long as the practicing podiatrist is in the office the assistant can take an x-ray without being certified. I unfortunately found out this wasn’t the case.
Although we did not take many x-rays in our office, enough were taken through the years that would have put me in a difficult situation had that not been reported. I did have legal defense through PICA and they put me in contact with a healthcare consultant. It turned out to be an expensive mistake. Working with the healthcare consultant, they contacted Medicare to explain my circumstance. Medicare appreciated our transparency, but still asked for a refund of $10,000 dollars. This amount was based on three years' worth of billing. Obviously, this was not a slap on the wrist, but if they would have discovered this error themselves via a whistle blower or disgruntled employee, they could have gone back, I believe, seven years or more if fraud was suspected.
You are doing the right thing by reporting this unfortunate situation but you must go about it the right way.
Name Withheld (FL)
07/05/2024
RESPONSES/COMMENTS (MEDICAL/LEGAL) - PART 1A
From: Alan Bass, DPM
This is very troublesome to hear. This is why it is so important to review your collections report, as well as your accounts receivables monthly with your billing company. At this time, I suggest the following steps be taken:
1. Contact your malpractice carrier and alert them to this and ask if your policy with them contains administrative defense coverage (ADC) and if it will cover any audits that may arise from this. Hearing that this was for skin substitute claims leads me to believe that these were for Medicare recipients and that can be very problematic.
2. Contact the billing company and alert them to their inappropriate billing practices. You should ask them to return any monies to you that they were paid on the inappropriate claims, since the monies reimbursed by the insurance carrier should be refunded to them.
3. Contact the insurance companies for these claims and inform them that you are aware that you were reimbursed inappropriately for certain claims and discuss reimbursing them for the inaccurate claims.
4. Contact your accountant regarding any tax implications this may have.
5. Consider switching your billing company. I would review the last several months of billing to see if this happened previously.
Disclosure: I am the owner of my own podiatric-specific billing company.
Alan Bass, DPM, JARALL Medical Management Consulting
10/16/2019
RESPONSES/COMMENTS (MEDICAL/LEGAL)
RE: Re-use of Single-Use Injectables
A podiatrist in a local hospital has been given by the nurses used single-use vials of Marcaine, Xylocaine, Celestone, and Decadron at the conclusion of his cases. He then uses these same single-use vials and re-draws from them to give injections to his patients. The illegality here is two-fold: First, this is fraud due to double billing, because the patient is charged for the full 50cc vial in the hospital, and then the patients are charged in the office for the same vial. Second, there are no preservatives in the single-use vial, hence the chance of infection is huge when using on multiple patients, especially when many of the patients are diabetics with infections. This podiatrist has been reported to the OIG as well as to the county health board.
A very similar situation had occurred in Las Vegas, in which a physician was doing the same thing, with the state health department coming in and having to contact all the patients who had been injected to check on their health and well-being. I foresee the same situation here in that the health department will come into his office, and have to contact all the patients who have received injections and place them on notice that they have been injected with a contaminated medication. This is only the beginning of the end, with the hospital now being liable also by allowing him to remove the medications from the hospital.
Name Withheld
03/19/2019
RESPONSES/COMMENTS (MEDICAL/LEGAL) - PART 1B
From: Elliot Udell, DPM
On the surface it may appear that unless you write prescriptions for narcotics, spending close to a thousand dollars to renew a DEA number seems unnecessary. The problem is that certain states will require a DEA number in order to prescribe other non-narcotic medications. At the SAM meeting, one of the speakers said that in the state of Florida, one must have a DEA number in order to prescribe Lyrica. Double check this if you practice in Florida. In New York, Ketamin trochies require that the prescriber have a valid DEA number. The bottom line is that you should survey what medications you prescribe and then ask the local pharmacy whether you need a DEA number to prescribe them in your particular state.
Elliot Udell, DPM, Hicksville, NY
03/18/2019
RESPONSES/COMMENTS (MEDICAL/LEGAL)
From: Matthew B. Richins, DPM
I had a patient who liked to hug (never “grabbing” or “touching” my staff). I took it as his being a sweet old man and thought nothing of it. One day, this got brought up in conversation with a lawyer friend. He told me that if he makes them feel uncomfortable, I know it is going on and I do nothing to prevent it, that is sexual harassment. The next day, I asked my staff their opinion on the patient. It turns out, they all thought he was creepy and they tolerated him because he was a patient. Needless to say, he was discharged that day and my staff appreciated knowing that they and their well-being came before patients.
In your case, that patient needs to be discharged at the least and a police report filed, if warranted.
Matthew B. Richins, DPM, Joplin, MO
03/02/2016
RESPONSES/COMMENTS (MEDICAL/LEGAL) - PART 1A
From: George Jacobson, DPM
There may be general and or specific requirements by your state or state board. For example, you may be required to publish legal notice of the closure with specific information required by your state. Ask a healthcare attorney in your state. When my oncological surgeon passed away a decade ago, I wanted to secure my records. There was a legal notice in the newspaper instructing patients. His estate had a third-party administrator maintain the records for a said period of time. I paid a fee for the records.
George Jacobson, DPM, Hollywood, FL
09/26/2015
RESPONSES/COMMENTS (MEDICAL/LEGAL) - PART 1B
From: William Deutsch, DPM
I have two suggestions for the DPM considering selling his practice and retiring.
1. Do not ratchet down your practice. Instead try increasing your income and patient load.
2. Market your practice to a podiatrist contented to do only forefoot/mid-foot surgery. After all, how many rear foot surgeries come breaking down your door?
As an alternative, market your practice to an enterprising orthopedist specializing in foot and ankle disorders and willing to open a foot treatment/wound clinic. Forget the hospital cutting podiatry a break. You might have to put your retirement off by a decade.
William Deutsch, DPM, Valley Stream, NY
09/26/2015
RESPONSES/COMMENTS (MEDICAL/LEGAL) - PART 1A
From: J.C. (Chris) Mahaffey, MS
If the Wyoming podiatrist referred to is an ACFAS member, please have him/her contact me regarding the College’s Credentialing and Privileging Advisors Team. We have a team of members, all of whom have served on a hospital credentialing committee, who can advise you on this matter. The College has other resources I would be happy to discuss with him/her.
J.C. (Chris) Mahaffey, MS, Executive Director, ACFAS
09/25/2015
RESPONSES/COMMENTS (MEDICAL/LEGAL) - PART 1A
From: John Chisholm, DPM
This is the type of problem that can be dealt with quickly and effectively by your local APMA/state local component association. Most state associations, in my case the California Podiatric Medical Association, have the knowledge, experience, and, if necessary, legal resources to correct any discriminatory position of your local hospital.
It is also a good example of why every podiatrist, in practice or retired, should belong to APMA and their state component association. In order to do this kind of work for its members, APMA needs everyone to pull their fair share of the load, and this includes the financial support of its dues-paying members. If you are an APMA member, contact your state component association and they will get this matter straightened out quickly. If you are not a member, then join today.
John Chisholm DPM, Chula Vista, CA
06/15/2015
RESPONSES/COMMENTS (MEDICAL/LEGAL)
From: William Deutsch, DPM
If the sole function of government were problem-solving, there would only be one voice heard, no need for a legislative or judicial branch. The purpose of government in a democracy is to offer the illusion that citizens also have a voice in decision-making. But it's just an illusion.
There is no reason to assume that solutions offered by government are wise, efficient, or competent. In the realm of healthcare overhaul, the purpose was simply to...
Editor's note: Dr. Deutsch's extended-length letter can be read here.
06/12/2015
RESPONSES/COMMENTS (MEDICAL/LEGAL)
From: Richard A. Stanley, DPM
I sympathize with Dr. Benjamin’s plight. These policies are pervasive in the EMR industry. I purchased an EMR program 6 years ago, for a rather large sum, which was located on MY server and the data backed up on MY external drive. Unfortunately, that firm filed for bankruptcy and was acquired by a new entity. Due to the reasons mentioned by Dr. Benjamin, I switched vendors as well. I have now been locked out of MY software still located on MY server unless I pay an outrageous sum. I am not sure what I paid for if I cannot access the software or my data. There are three years of medical records present in that software that were entered prior to their acquisition. I do not take being held hostage kindly. It is time for legislation and/or EMR licensing rules that require a read-only file be provided at no additional cost in the event of a termination.
Richard A. Stanley, DPM, Indianapolis, IN
12/22/2014
RESPONSES/COMMENTS (MEDICAL/LEGAL) - PART 3
From: Tom Zoldowski, DPM
I have gone through this same situation with hospital privileges. I met with the hospital credentialing committee, explained that I don't do a lot of surgery, that I do use the hospital facilities and services for out patient testing, that this hospital is where I do 90% of my surgery, and I am involved in the residency program. The committee then allowed an exception.
Tom Zoldowski, DPM, Toledo, OH
12/22/2014
RESPONSES/COMMENTS (MEDICAL/LEGAL) - PART 1B
From: Jim DiResta, DPM, MPH
It has been my experience that credentialing committees will accept activity at another facility where you maintain privileges in lieu of not seeing enough patients at their particular facility where you lack the minimum 20 patient encounters over the 2-year period. This is a fairly common occurrence and protects the hospital in recredentialling you for medical staff membership. Often there are two parts to this. One is hospital membership where you need patient contacts, i.e. inpatient consults, out patient treatments, OR procedures, or activity in the hospitals wound care center. The second is surgical privileges. Many surgical departments are now requiring certain volume thresholds of surgical procedure activity to renew providers privilege cards. Satisfying that request is more daunting.
The other issue Dr. Borreggibe raises as to whether you should voluntarily relinquish your privileges or allow the facility to not renew them is a question that I would seek out legal counsel as you will be asked this question on numerous renewals for third-party payer contracts, ACO involvement, healthcare privilege applications and license renewals, etc.. and it would appear taking a proactive course of voluntarily giving up your membership and privileges would be wiser with a reason that you simply no longer need use of that facility for non-renewal rather than allow them to "take your privileges away" and have to continually explain that to other parties in the future.
Jim DiResta, DPM, MPH, Newburyport, MA
12/22/2014
RESPONSES/COMMENTS (MEDICAL/LEGAL) - PART 1A
From: Elliot Udell, DPM
Many physicians are faced with this same problem. They do not admit too many patients to their local hospitals yet need to verify that they are on staff of a hospital for the purposes of insurance credentialing. What our local hospital system has done was to create an on-staff privilege, which does not allow the doctor to admit patients but allows him or her to read charts and visit but not treat patients. It is a win - win situation for the physician and the hospital. On one hand, the doctor no longer feels impelled to admit more patients than is necessary and on the other hand the hospital still makes their share of dues from each practitioner.
Elliot Udell, DPM, Hicksville, NY
12/18/2014
RESPONSES/COMMENTS (MEDICAL/LEGAL) - PART 1B
From: Elliot Udell, DPM
A friend of mine called me over the weekend asking me about similar paperwork she had to sign in order to gain admission to a motivational seminar in New York City. I could not imagine anyone suing them over not "being motivated"; however, what they may be concerned with is if she is not happy with the program, leaves early, and wants her six hundred dollars returned.
This would go to arbitration. This might be what is so with the orthopedic group. With high co-payments with the new insurance plans, many patients might run up a bill for a couple of thousand of "out-of-pocket" dollars and look for ways to not pay the bill. Some patients truly believe they are covered for all services, and then refuse to pay even though the visits went toward a four thousand dollar deductible. In other cases, the patients might claim they do not owe money because their knees or shoulders did not feel better. I cannot see a court allowing a patient to sign his or her rights to sue for professional negligence.
Elliot Udell, DPM, Hicksville, NY
12/18/2014
RESPONSES/COMMENTS (MEDICAL/LEGAL) - PART 1A
From: Donald R Blum, DPM, JD
"....When I received the new patient paperwork, an arbitration document was included in the packet for me to sign. It basically stated that if I felt dissatisfied in the care I received and I was considering a medical liability claim, I could arbitrate the matter with the institution where the care was provided instead of a seeking legal counsel."
I think the key word in the notice is "could". To me, this is giving you the option to arbitrate versus making it the only option. Please do not construe this to be legal advice. I also suggest asking them the meaning of the notice.
Donald R Blum, DPM, JD, Dallas, TX
12/13/2014
RESPONSES/COMMENTS (MEDICAL/LEGAL) )
From: Gary Hoberman, DPM
I think the elephant in the room is not what criteria is needed for a home visit but the fact that most doctors we interview to work in nursing homes who are currently doing home visits are billing for an E&M visit EVERY single visit along with the at-risk palliative care they may be providing. Somehow they find tinea, or some other emergent problem that just happens to pop up on the 60-day cycle with the necessary and presumed covered palliative care. This leads to a higher average fee per patient and a competitive advantage for those practices seriously engaged in home visits. I’m glad these E&M codes are now being more closely scrutinized.
Gary Hoberman, DPM, Chicago, IL
09/02/2014
RESPONSES/COMMENTS (MEDICAL/LEGAL) - PART 1B
From: Seth J. Steber, DPM
There is a group you can join called Doctor's Advocate: doctorsadvocate.org. For less than your state and national dues, you can become a member. Their attorneys and staff will handle independently any potential lawsuit, PR issues, threats, slander, etc. Since they are not an insurance company, they can contact your potential plaintiff and their attorney directly to discuss the matter and "educate" them on frivolous lawsuits and potential for counter-suits.
09/02/2014
RESPONSES/COMMENTS (MEDICAL/LEGAL) - PART 1A
From: Jeffrey Kass, DPM, Elliot Udell, DPM
I fail to see how "name withheld" is a serial malpracticer when no judgment was made against him. I would have taken issue with the hospital.
When I first started in practice, podiatrists were getting sued, and our premiums were sky high. Why? Insurance companies were willing to settle every lawsuit, whether it had merit or not. Every negligence attorney knew that suing a podiatrist meant a quick settlement with very little work. For the insurance industry, it was cost-effective to settle every case and raise everyone's premiums at the end of the year, and even add on more profits for themselves. They did not care one iota that settling an unwarranted med mal case would be on a doctor's record and interfere with his or her ability to be on staff of certain hospitals. Today, carriers fight back and, unlike the past, they cannot force doctors to settle bogus, nuisance cases.
08/29/2014
RESPONSES/COMMENTS (MEDICAL/LEGAL) - PART 1B
From: Elliot Udell, DPM
Dr. Jacobs is correct when he states, "In-office compounding has been around a long time." My dad is a retired pharmacist. When I was little kid in the 1950s, I remember visiting his drug store. In those days, pharmacists were not highly educated professionals. Their roles were often reduced to taking pills out of a stock bottle, counting them out into a small plastic bottle, and slapping a label on it. In those days, all physicians wrote for compounds, and my father showed me how he would hand-make ointments, cough syrups, pills, and suppositories based on physicians' prescriptions (which were always written in Latin). With compounding pharmacies, the profession has come full circle and pharmacists are once again doing the work that measures up to their years of intense training.
08/28/2014
RESPONSES/COMMENTS (MEDICAL/LEGAL)
From: Allen Jacobs, DPM
In-office compounding has been around a long time. There is nothing wrong with compounding selected pharmaceutical ingredients in your office for patient treatment. The issue your question raises is not about Stark Law. It should be about medical liability, kick-back laws, ethics, and not jeopardizing your in-network medical status with payers.
1. Liability is a major issue. When a pharmacist dispenses a drug to a patient, they hold 100% of all patient liability for safety around allergies, drug to drug interactions, contraindications and...
Editor's note: Dr. Jacobs' extended-length letter can be read here
07/22/2014
RESPONSES/COMMENTS (MEDICAL/LEGAL) - PART 1B
From: Peter Bregman, DPM
It is possible that the patient had an underlying tarsal tunnel syndrome that was exacerbated by this injury. It will be difficult to prove this. It is also important not to rely on EMG/NCV studies and document the clinical presence by Tinel's sign and by provocation. Is also important to look more proximately at the soleal sling as well for tibial nerve entrapment.
07/18/2014
RESPONSES/COMMENTS (MEDICAL/LEGAL) - PART 1C
From: Richard A. Simmons, DPM
The doctor is asking how to chart for an unchanged condition of a painful fifth toe corn every two months, for decades, on a patient not wanting a surgical correction. The patient is happy with conservative care. The answer is simple: you chart the treatment you are doing on a routine basis, whether it is repetitive or not.
Now, if the patient’s bill is paid for by Medicare, please be sure that the patient meets Medicare’s criteria for “covered” routine foot care (CPT 11055). Do not bill an E&M (evaluation and management) code for each visit. If the patient is not eligible for routine foot care, then this is a cash visit with no bill submitted to Medicare. Check with the criteria for other insurance carriers before submitting your claim.
Editor's note: Name Withheld has informed us that the patient was considered at-risk and covered for care of the fifth toe corn.
07/18/2014
RESPONSES/COMMENTS (MEDICAL/LEGAL) - PART 1B
From: Brian Kashan, DPM
One of the factors in repeated treatments and visits, in my opinion, is if it is for a covered service or not. If it is not a covered service, i.e., routine care in a non-diabetic, I do not believe that repeated notes are as much of an issue. If it is for a covered and billed treatment, I believe there is a definite need for different documentation.
While most repeated visits can be 95% exactly the same, there are small variants from visit to visit. A note of social changes, illnesses, medication changes, or the lack thereof, can be noted. The size and severity of the lesion from visit to visit may change. Some skin irritation or nail subtlety may be present. It doesn’t have to be a huge difference, but just a few words that make that day's visit somewhat different, so someone can determine that day was different from any other day. Patients relate all kinds of things to us during their visits. I suggest jotting down a few words that they relate happened, or that you observe from visit to visit.
07/18/2014
RESPONSES/COMMENTS (MEDICAL/LEGAL) - PART 1 A
From: Stephen Musser, DPM
In the subjective part of your note, I would document changes in the patient's PMH and up- coming test/procedures. It's hard to believe there would be no changes after decades of treating the patient. In addition, document (every visit) in the plan that you reviewed the patient's current medications and allergies.
|
| |
|
|
|
