03/21/2014    Brian Kashan, DPM

178K Out-of-Network Payment to NY Podiatrist Spurs Investigation

While I rarely get surprised by anything these
days, I have to admit that this unfortunate story
left me speechless. This exemplifies the hypocrisy
of our health care system, and the selfishness by
some trying to stuff their pockets regardless of
the repercussions. I am not only referring to some
provider’s greed, but the insurance carrier’s
greed that may sometimes cause the provider to
rationalize the over-the-top behavior as some sort
of revenge.

The provider-insurance carrier relationship has
frequently been adversarial. Ridiculously low
reimbursements, policy changes, and restrictions
have sometimes been met with increased
utilization, and “creative” billing to offset
those changes. This is met with more policy
changes and then more creative billing, so on and
so forth. However, submitting a bill for several
hundred thousand dollars to an insurance company,
in my opinion, is an insult to our profession and
the epitome of selfishness.

Years ago, I recall the car makers in Detroit
eliminated podiatry from most of their plans. The
basis of this was the usual number of claims and
procedures being performed by podiatrists. The
result was extreme hardship for many of our
colleagues who practiced in this area. When people
believe that their actions do not affect others,
and that they will fly under the radar because
they are only one small individual in an ocean of
fish, outlandish examples like this flourish.

While there are many failures in this particular
example of $178,000 for several small surgical
procedures, the results of this will have
widespread implications. Once again podiatry will
be looked upon as a greedy profession, creating
problems within the healthcare system that will
result in limitations and restrictions. Believe it
or not, what each of us does affects all of us. We
do not practice in a bubble.

My first reaction when I read this story was how
many of us struggle to abide by the policy and
rules in a shrinking reimbursement pool, have to
bill by the number of toenails trimmed, the number
of corns cut, provide medical documentation,
reports, and try and abide by government mandates
and requirements on an increasing basis. If I
provide services to a diabetic patient, one day
before the 61-day requirement for covered
services, my claim gets rejected. If I forget to
put a modifier on a claim, my claim gets rejected.
If I don't submit a claim in six months, my claim
gets rejected. If the patient changes their
insurance and doesn't inform us correctly, through
no fault of our own, our services are rejected.

The insurance companies can go back and audit our
records and retract payments that they may
unilaterally feel are incorrect. These examples
can go on and on. Then I see that an insurance
company paying $178,000 for relatively minor
procedures, and I ask myself what is going on
here. There is such scrutiny on one hand, and not
enough scrutiny on the other.

All I can say is that we each have to look
ourselves in the mirror every morning. Do not
develop the attitude that you are doing something
wrong because you are doing something right. The
excuse that everyone else is doing it is just not
correct. Everyone else isn't doing it. Most of us
are going above and beyond in our efforts to
provide care and comply with so many changes.
Healthcare is changing and we must change with it.
However, that does not give us the right, nor
justification to selfishly engage in activities
that are harmful to everyone involved and have
large repercussions for so many.

While a $178,000 deposit in your bank is quite
impressive, the cost to all of us are
immeasurable. In this case, I would hope that
common sense prevails, appropriate reimbursement
made for the services provided, and that proper
action be taken by all parties to prevent this
from happening again.

Brian Kashan, DPM, Baltimore, MD, drbkas@att.net

Other messages in this thread:

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03/19/2014    Simon Young, DPM

178K Out-of-Network Payment to NY Podiatrist Spurs Investigation

It seems outrageous that foot surgeons out-of-
network charges are paid with such little
oversight. As usual, podiatrists are not the only
practitioners involved in this practice, but in
this case a podiatrist took it to a different
level of greed.

How is this different from what insurance
companies do to the in-network doctors who are
part of the solution to our healthcare crisis.
The multiple of millions of dollars needlessly
denied for proper services billed.

United healthcare/oxford screws me regularly and
twice on Sundays. I love their one penny checks. I
love how they try every trick in their bag of
tricks to deny my services. I love how they won't
help you with billing issues you have. There are
thousands of examples.

What about lies, misrepresentations from all these
insurance companies such as BC/BS, UHC, etc to
deny coverage after preauthorization is garnered.

The State "for the" insurance department of New
York does nothing.

NY State Podiatric Medical Assoc wants forms and
is generally ignorant even when presented with
obvious "no-brainer" evidence and cant understand
why members don't inform NYSPMA. Members of the
insurance committee can't understand my
handwriting, but won't review the denial codes.

Many practitioners are hemorrhaging money and I
don't see an emphasis to rectify these injustices.
Ankle privileges in NY is more important than
helping members earn a basic living and of course
our outrageously hi dues.

No doubt Dr. Levine's greedy actions will impact
every in-network provider while she lived high on
the hog on Park Ave. Toting her skills to the
profession through pricey seminars and selling her
line of "cosmetics" for feet, while perpetuating
this outrageous practice. Such unspeakable
narcissism and professional moral and possibly
ethical fraud. I am surprised it wasn't realized
sooner.

When will the doctors attack the legislators and
state "for insurance" departments to examine these
"insurance middle men"with the same veracity,
scrutiny, and intensity United Healthcare ?will
impose on Dr. Levine. Rightfully so on both sides
of the aisle.

Simon Young, DPM, NY, NY Simonyoung@juno.com