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01/27/2014 Michael M. Rosenblatt, DPM
Elimination of RFC Patients
Routine foot care patients have been the very basis of DPM practice ever since the need for our services started to exist. Even though I owned and operated a Medicare certified Surgical Center, I still saw RFC patients. Often I was glad to see them listed, because a large surgery schedule is tiring (even exhausting) and RFC requires much less thinking or planning. It is also necessary, even if Government and private insurers are unwilling to pay for it.
The crux of the issue: patients expect it for free or universally covered by insurance. I think even Kaiser has problems with this, with expectation of coverage, or at least a very small co-pay. Medicare regulations compound the difficulty in getting paid, because if there is even the slightest chance of coverage, the Medicare laws shadow your charges. I recommend a few possibilities:
1. Consider reducing, rather than excluding RFC from your practice 2. Offer a charity event, like free monthly RFC at a local community or public retirement center (I did this for 20 years). When patients want it for free, advise them the date/time you will appear at the community center and invite them to come. Be cheerful and proud of your service. 3. EDUCATE office patients to understand that if it is not covered by insurance, THEY must pay for it. 4. If they are covered by insurance you MUST charge them the deductible and co-insurance. It is Medicare fraud not to. 5. Provide each RFC patient (whom you think may not be covered) with an Advance Beneficiary Notice (http://www.medicare.gov/claims-and- appeals/medicare-rights/abn/advance-notice-of- noncoverage.html) Make sure you get their signature each time you think it's necessary. It may be illegal to bill them without this notification. 6. When RFC patients go doctor shopping for free RFC, they are imperiling the doctors (and their families') who do this and fabricate illegal coverage data. The irony is that those very patients will be the first to turn you in for illegal services. 7. Explain to militant patients that fabricating billing is illegal and punishable by jail and loss of license.
Finally, patients must learn that RFC is not free and is not often covered by insurance. I admit this is an uphill battle. But you have a right to be paid for these services and not risk going to jail and losing your license over it. Government expects you to provide it for free in extended care facilities. It is unreasonable to bring that expectation into your office too. Militant cost- cutting, demanding for-free patients should go elsewhere. Life is short. Dealing with them is unpleasant and difficult for both you and your staff. You're better off studying for your boards or reading journals than arguing with them.
Michael M. Rosenblatt, DPM, San Jose, CA, Rosey1@prodigy.net
Other messages in this thread:
02/03/2014 Michael Forman, DPM
Elimination of RFC Patients (Simon Young, DPM)
Again I agree with Dr. Simon Young - this time in reference to "routine" and "at-risk" foot care. This service is in the domain of the podiatrist and that is where it should stay. I can accept healthy patients seeing a pedicurist if they choose, however all "at risk" patients must be seen in a podiatry office.
It is wonderful that so many of our colleagues are so busy that they don't want to bother with this type of patient. This is the patient who needs us the most. I have several podiatric colleagues who do only foot and ankle surgery. That's great and speaks well of our profession. Many of our three year resident graduate choose not to do conservative care. That certainly is their choice.
I see another avenue for the rest of us. I feel that podiatry is in the same place that dentistry was in fifty years ago when dentists performed their own oral prophylaxis. Not so today. Dentists employ dental assistants dental hygienist, and a new super assistant who is trained to do restorations.
It is time for podiatry to catch up. I employ two assistants who I have trained to do conservative care. They are artists who do the best "CNC" that I have ever seen (without blood letting). They don't make diagnoses. They trim toenails and keratomas under our direction. One of our doctors ALWAYS sees the patient, sometimes twice during the visit. particularly at the end of the visit. Approximately 20% of these patients will complain of another problem which is addressed at that time. This is what keeps our practice busy. Ohio specifically states in the revised code that an assistant can perform any task if they are properly trained, capable of successfully performing the duty, and under the direct supervision of a physician.
I believe the majority of podiatrists should have full service practices that offer the gamut of foot and ankle care. Let's keep foot care in our field.
Michael Forman, DPM, Cleveland, OH, im4man@aol.com
02/03/2014 Burton J. Katzen, DPM
Elimination of RFC Patients
I always get a kick out of our profession’s younger generation when they write in about getting rid of routine foot care patients. First of all, as a matter of perspective, my career in podiatry ranges from 1967, the end of the chiropody era when chiropodists took weekend courses at PCPM to get their DPM degree, to the present era of external fixators, total ankle replacements, etc.
In other words, I have been there from the beginnings of the modern era. My post-graduate training consisted of arguably the finest surgical residency in the country at that time, Civic Hospital, under the tutelage of “the father of foot surgery”, Earl Kaplan, and Irv Kanat, and Sol Luft. The residency was all of 8 months, which recently had been expanded from 6 months.
After reading several of these posts, I am reminded of a long forgotten article in the late '60s which appeared in a medical journal entitled “Whither Podiatry”. The gist of the article was what the future of podiatry was going to be and furthermore, why do we even need the podiatry profession at all? Then, as now, as the article stated, there are orthopedic surgeons to treat athletes and perform bone and joint surgery, dermatologists to treat skin and nail conditions, infectious disease specialists, pediatricians, etc.
The answer was obvious to most of us at that time. As my mentor, the late, great Charlie Turchin said at the time, the reason we exist at all is that we are the only profession that can have a patient come to our office in pain and leave with no pain – yes the dreaded ROUTINE CARE PATIENT.
As the profession advanced from the first generation of surgeons in the “70’s”, I believe that many of our graduates of that era unfortunately had an inferiority complex about not being what in the old days we used to call “R.D.’s (real doctors). Therefore, in order to become R.D.’s, we felt the need to try every screw, every plate, and every procedure that was put in front of us while shunning and even going in the exact opposite direction of minimally invasive procedures that every other medical specialty was exploring and embracing. While we became better surgeons, I believe we lost sight of why we had existed as a profession for the previous 70 or 80 years.
So where has that left us today? We are now a profession that graduates many students who can’t get residencies, and we are now the only branch of medicine that forces all of our graduates to become surgeons just to get a license to practice in most states, all in the interest of parity (the RD complex rearing its ugly head again?). From my anecdotal experience, our schools and 3 and 4 year residency programs have not trained our young graduates to provide passable routine foot care nor conservatively manage and interact with patient as well as the previous generations.
We are wasting the talents of many of our graduates and denying thousands of patients needed and necessary treatment. Think of the number of patients who could be receiving treatment by the steadily rising “unable to get licensed” podiatrists who would love to be providing valuable and necessary routine foot care. To all our young graduates and practitioners, THIS IS WHY WE EXIST AS A PROFESSION TODAY! Not because of our ability to perform surgery.
Thank the Charlie Turchins, the Lennie Hymes, the Earl Kaplans and Irv Kanats for their expertise in pioneering my generation of podiatrists and providing the opportunity for us all to be where we are today as a profession.
Finally, though I practice less hours than before, I still treat a whole lot of patients every day, perform a great deal of surgery, and still have a whole lot of time for routine care patients. I also, find time on some afternoons off to service four senior citizen homes, many of the non- eligible patients for free. Why? Because I enjoy it. I would suggest that anyone who thinks they do not have the time to help these people because the remuneration might not be to their liking, you may be in the wrong profession or have serious time management problems.
Believe it or not, besides having the most fun in my practice when kibitzing with and helping these appreciative patients, these routine care patients often become surgical patients, orthotic patients, and even refer the kind of patients you “really want to treat.” While we all want to make a nice living, as Dr. T used to say, “treat the patient, not the pocketbook, and you’ll be a happier person”. This great profession of ours has given most of us a pretty darn nice life style, so always remember “Whither Podiatry.” Burton J. Katzen, DPM, Temple Hills, MD DrburtonK@aol.com
01/30/2014 Lawrence M. Rubin, DPM
Elimination of RFC Patients
I graduated from the Illinois College of Podiatric Medicine in 1958, but I embarked on the road to becoming a podiatrist in 1954, when the college's name was the Illinois College of Chiropody and Foot Surgery. You no doubt recognize the fact that I am an "old timer." Age does not assure wisdom, but it does help to put a perspective on things that relate to the long term welfare of our beloved profession.
I agree with Dr. Kiel and Dr. Ryder. Please do not abandon so-called "routine foot care" ("routine" being the term that denigrates the service that can save the feet and legs and sometimes the lives of diabetics and other at-risk patients.) In my humble opinion, you will be throwing out the baby with the bath water. Although the overall quality of foot care in our country would plunge if there is a podiatric abandonment of routine foot care, from a marketing point-of-view and from a "coping- with-Obamacare point-of-view," if podiatrists abandon routine foot care, other medical specialties will take charge of foot health care in this nation.
Dermatologists will get all the skin and nail foot problems and will hire pedicurists to perform routine foot care; orthopods will inherit the surgery; rheumatologists will treat painful heels, etc, etc. I know this much for a fact: Here in Las Vegas, many podiatrists are being dropped from many insurance panels. To counter this, we have formed a Las Vegas-Henderson Nevada network of podiatrists who provide amputation-prevention foot care that includes, but is not limited to, "routine foot care" for diabetic and other patients who are at-risk of foot complications and amputations.
It is precisely the undisputed ability of the podiatrist to provide the highest quality, comprehensive preventive, "routine" foot care for at-risk patients that is opening the doors for podiatrists in closed panels and panels that are shaving down their networks in Las Vegas.
Insurers may not love podiatrists, but they sure love the money we can save them by reducing the costs of the chronic foot complications that lead to amputations and the amputations themselves. And, I am sure the patients whose limbs are preserved appreciate us too.
Lawrence M. Rubin, DPM, Las Vegas, NV,lrubindoc@aol.com
01/25/2014 Brian Kashan, DPM
Elimination of RFC Patients
I have this debate periodically, with some of my colleagues, who have the exact same complaint as you. Namely, that they are inundated with RFC patients and new patients have to wait weeks to get in. This results in many of the new patients going to another doctor, as they can’t wait weeks for an acute problem. The loss is huge.
I have several suggestions. If possible, perhaps you can stretch out the time between visits for the RFC patients. Let’s say from 8 to 10 weeks. Then, RAISE YOU FEE FOR THIS SERVICE. As RFC is a non-covered service, you can determine what you want this fee to be and the patient will either pay it or go elsewhere. I don’t consider that to be a loss, as most of us undercharge for RFC anyway. We generally have one fee for RFC, whether the patient has a few long nails, or a patient has 20 calluses and corns and wants each one trimmed to the last cell of the epithelium and has to have each one padded.
Or how about the patient that comes in every 6 months or a year with their feet in horrible shape, and tells you to cut everything “as short as you can”. Consider multiple levels of RFC, like there are for E&M services. There can be a low level, intermediate level, and high level of RFC, depending on what you are doing. I think that is reasonable and within legal bounds. We bill our covered diabetic care for nail and lesion debridements separately, so I assume we can also consider billing our non-covered RFC similarly.
Regardless, I recommend leaving a couple of slots a day open, so urgent patients can be put in and you don’t lose them. This is just my opinion, and of course subject to all the laws, rules, and regulations we all deal with on an everyday basis.
Brian Kashan, DPM, Baltimore , MD, drbkas@att.net
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