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

Other messages in this thread:

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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

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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

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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

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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