01/07/2015    Jeff Kittay, DPM

Therapeutic Diabetic Footwear Collapse (Bryan C. Markinson, DPM)

Given all the recent comments regarding the
Medicare Diabetic Shoe program in PM News, I am
suggesting a new subject for a poll. What
percentage of DPMs went to podiatry school and
three-year surgical residencies in order to sell
shoes? The primary reason I read from our
colleagues endorsing participation concerns a
"revenue stream" that we shouldn't miss. Really?
Is that how we are making our livings now? And is
revenue enhancement the best reason to join up?

Please do not misinterpret my lack of
participation with any DME program as suggesting
that such shoes, orthotics, etc. are unneeded. On
the contrary, they are vital to the well being and
indeed survival of many of our patients. But let
the professional orthotists who know their
business inside and out do their work and let us
do ours.

Spending so much time and effort in your practice,
hoping that you will survive an audit by a
government agent whose sole purpose is to recover
money does not seem, to me at least, a good use of
your valuable time.

Likewise, all the effort being expended to comply
with "meaningful use" in EHR, with constantly
moving governmental goalposts, seems equally
pointless. I, like many of you, have endeavored
since graduation to run and promote an honest,
full-scope podiatric practice that I can be proud
of, one that permits me to sleep soundly at night,
and that would permit me a reasonable living.

I did not attend podiatric medical school in order
to become a shoe or orthotic salesman, subject to
the whims of a government run completely amok in
contradictory rules and regulations. It is most
disheartening to read about colleagues being
financially penalized by Medicare for not having
hours posted for shoe dispensing, having a 2%
sequester reduction in already penurious fees
imposed, and this past week, a letter advising me
of another 1% reduction because I do not have, and
will not have, EHR in my office.

While on active duty in the Navy in the early
1970's, even as I bristled with some of the
nonsensical rules in effect at the time, I knew
the government had my back. Today, I am not an
employee of the government, but instead now am
treated as less than one, in fact as an adversary.
We are subject to rules that dramatically impact
our incomes, and coerced into purchasing and
utilizing EHR programs purportedly designed to
make health information more accessible, while
many of the platforms available cannot communicate
with one another.

I am hopeful that as I wind down my time in
practice later this summer, that I will be able to
find a hopeful graduate of a residency program
looking to practice in my city, but I admit to
some concern regarding his/her welfare in the
future.

Jeff Kittay, DPM, Boston, MA

Other messages in this thread:

---

01/04/2015    Paul Kesselman, DPM

Therapeutic Diabetic Footwear Collapse (Bryan C. Markinson, DPM)

The complexities and document requirements of the
Medicare diabetic footwear program have run indeed
run amok, but to the degree depends on whom you
speak with. From the perspective of large
commercial suppliers, who are used to having to
obtain complex and multiple documents from various
prescribing entities, this is nothing new. Nor is
this type of level of documentation requirements
new to the orthotics and prosthetics industry, who
often have dire consequences if a claim for a $40K
prosthetic is rejected due to a lack of
"medical necessity."

Speaking with those in the industry of both off
the shelf and custom shoes, many manufacturers
have told me that while they may have lost some
business in the podiatric segment of the market,
the orthotic and prosthetic segment of their
marketplace has grown significantly in 2014. The
BMAD will not reflect this until 2016, so rather
than wait for that, one has to explore further.

The issues which Dr. Markinson speaks to however
are real and justified and he is certainly
correct. Where we both practice, the costs of
doing business are among the highest in the
nation. This often makes the fee schedule rather
unprofitable or at least frustrating to deal with
when attempting to secure a quality product and
yet still make economic sense for one's practice.

But there is far more to it than just a simple
cost analysis and decision to reject your
continued participation in the Therapeutic Shoe
program. Most responders to inquiries from APMA
AOPA and other organizations to their shoe
provider constituents, indicates that only a very
small number (if any) are subjected to any sort of
audit. This means that most claims are paid
without an issue. This is also true for those who
have been audited in the past and have passed, yet
continue to be audited and who may fail those
audited claims. Its hard to understand why this
happens and feel compelled to continue to subject
yourself to this risk and harassment (and yes I
believe it is exactly that).

For those who are audited, and for whom Medicare
speaks of a 90% rejection on pre payment audit,
one must keep in mind that approximately 25 to 33%
of those are never answered (leaving one to wonder
whether the shoes were ever dispensed at all -do I
hear fraud? or are suppliers, in particular larger
suppliers, simply choosing to take a loss on those
claims and move on). What matters is that the
remaining number of claims, initially rejected are
overwhelmingly paid upon any level of appeal (in
excess of 65%). In my experiences with assisting
suppliers with appeals, the same documentation
which fails at the pre-payment carrier level
passes on some level appeal. The question one must
pose is why is that? The answers are far too
complex and lengthy to discuss in this forum.

As for the costs of custom molded shoes and the
crisis, to which Dr. Markinson speaks to, I would
tend to agree, that Medicare pays far too little
for custom fabricated shoes and this is indeed
become a problem. The costs to fabricate these are
indeed significant (over $250) and to the point of
not wanting to bother when one adds all the costs
associated with obtaining the required data and
the risks of audits and hiring consultants.

However, there are cost effective methods to
assist your office with attempting to stay
profitable:

1) Recent studies indicate that of all orthopedic
shoes sold in the US, only approximately 10% of
patients requiring and receiving orthopedic shoes,
require them to be custom fabricated. Thus what
Dr. Markinson speaks to at least with regards to
shoes is only a small segment of the population;

2) Farm these difficult cases out to those who
are experts. The costs of sending shoes back and
forth will quickly eat away at any profits.
Patient and supplier frustration at the process
may disenfranchise your relationship with the
patient. Farming these out will also allow you to
bill for an e/m each time the patient comes in to
you for an evaluation of their footwear
prescription. This is no different than evaluating
a patient's response to PT or medication you have
prescribed;

3) If you are going to supply custom fabricates
shoes, endeavor to have a cool head and be sure
you, your staff and the patient have a proper
level of expectation. Tell them, this will be the
ugliest pair of shoes you've ever seen or worn,
but at least they will be able to walk with the
knowledge that the shoes are limiting their
potential for further foot problems;

4) Use a manufacturer who will remanufacture or
repair a poorly fitting shoe for free, no
questions asked. Use one who will come to your
office and teach you how to cast and/or to assist
you with a difficult case and one who can provide
customer support for difficult cases, both before
and after casting. There is a very high learning
curve with this product. Be prepared to fail a few
times. Everyone who eventually succeeds has
numerous failures to discuss;

5) Use a manufacturer which has a set price (e.g.
$250 for a pair of shoes), with one pair of
inserts, in particular for those which will be
billed to Medicare;

6) Be sure you understand the coding for the other
modifications; Simply because a third party payer
has a limit on coverage does not mean you
provide the patient with those other modifications
for free (see next);

7) Don't swallow the extra costs for those
modifications Medicare (or other third party
payers won't pay as they are in excess of the two
additional add on codes they will pay for). Those
"extras" are required modifications for a proper
shoe fit and to reduce the patients risk of
developing further issues. Properly educate the
patient on this before you cast. Be sure they
understand their financial responsibilities for
any required add on costs not covered by their
third party payer and of course properly document
this (ABNs, etc.);

8) Ask someone in your office (other than
yourself) who understands the third party policy
to review the documentation you have received from
the MD/DO and your own documentation which may
have required some agreement from the MD/DO. A
second pair of eyes is mandatory for this (even I
have my office staff do this). My patients are
educated that we will not cast, measure or order
any custom fabricated product or even order or
dispense any off the shelf DMEPOS item, until my
office is satisfied we have obtained the required
documentation and that it will be sufficient on
the date the item may be dispensed (which could be
4-6 weeks later).

9) Don't feel pressured to do provide this level
of service for all patients. Just as you "walk
away" from patients who you feel may be poor
candidates for surgical care, do the same with any
DME service, if your gut tells you to do so. Its
just not worth ruining your day (week, month or
year) over a disgruntled patient who your office
staff (or anyone else's for that matter) may not
be able to satisfy.

10) Take the option of being a non participating
supplier. You can accept assignment, take partial
payment from the carrier and balance bill the
patient. Bear in mind you cannot do this, if you
are a participating physician under Medicare
provider and both your supplier and physician NPIs
are linked to the same tax identifier.

11) Follow the Kenny Rogers mantra, know when to
fold em, know when to run away and know when to
hide.

As for the whole therapeutic shoe program, if we
give up on this, you're just sending Medicare a
clear message to continue to go ahead with undue
audits and harassment at a time when many in the
O&P industry are clearly not. What's next? At risk
foot care? Will you give up that most basic of
service when those audits start? What will be
left?

The additional issue(s) here are that many
patients requiring custom shoes, also require toe
fillers and/or AFOs and other prosthetic products
which are outside the scope of the therapeutic
shoe program. These are additional revenue
generating sources which may not be available to
your practice if you were to outsource shoes to an
orthotist, pedorthist or other supplier type. I
cannot stress the importance of not neglecting
this income stream.

Paul Kesselman, DPM, Woodside, NY

---

01/03/2015    Paul Kesselman DPM

Therapeutic Diabetic Footwear Collapse (Bryan C. Markinson, DPM)

The complexities and document requirements of the
Medicare diabetic footwear program have run indeed
run amok, but to the degree depends on whom you
speak with. From the perspective of large
commercial suppliers, who are used to having to
obtain complex and multiple documents from various
prescribing entities, this is nothing new. Nor is
this type of level of documentation requirements
new to the orthotics and prosthetics industry, who
often have dire consequences if a claim for a $40K
prosthetic is rejected due to a lack of
"medical necessity."

Speaking with those in the industry of both off
the shelf and custom shoes, many manufacturers
have told me that while they may have lost some
business in the podiatric segment of the market,
the orthotic and prosthetic segment of their
marketplace has grown significantly in 2014. The
BMAD will not reflect this until 2016, so rather
than wait for that, one has to explore further.

The issues which Dr. Markinson speaks to however
are real and justified and he is certainly
correct. Where we both practice, the costs of
doing business are among the highest in the
nation. This often makes the fee schedule rather
unprofitable or at least frustrating to deal with
when attempting to secure a quality product and
yet still make economic sense for one's practice.

But there is far more to it than just a simple
cost analysis and decision to reject your
continued participation in the Therapeutic Shoe
program. Most responders to inquiries from APMA
AOPA and other organizations to their shoe
provider constituents, indicates that only a very
small number (if any) are subjected to any sort of
audit. This means that most claims are paid
without an issue. This is also true for those who
have been audited in the past and have passed, yet
continue to be audited and who may fail those
audited claims. Its hard to understand why this
happens and feel compelled to continue to subject
yourself to this risk and harassment (and yes I
believe it is exactly that).

For those who are audited, and for whom Medicare
speaks of a 90% rejection on pre payment audit,
one must keep in mind that approximately 25 to 33%
of those are never answered (leaving one to wonder
whether the shoes were ever dispensed at all -do I
hear fraud? or are suppliers, in particular larger
suppliers, simply choosing to take a loss on those
claims and move on). What matters is that the
remaining number of claims, initially rejected are
overwhelmingly paid upon any level of appeal (in
excess of 65%). In my experiences with assisting
suppliers with appeals, the same documentation
which fails at the pre-payment carrier level
passes on some level appeal. The question one must
pose is why is that? The answers are far too
complex and lengthy to discuss in this forum.

As for the costs of custom molded shoes and the
crisis, to which Dr. Markinson speaks to, I would
tend to agree, that Medicare pays far too little
for custom fabricated shoes and this is indeed
become a problem. The costs to fabricate these are
indeed significant (over $250) and to the point of
not wanting to bother when one adds all the costs
associated with obtaining the required data and
the risks of audits and hiring consultants.

However, there are cost effective methods to
assist your office with attempting to stay
profitable:

1) Recent studies indicate that of all orthopedic
shoes sold in the US, only approximately 10% of
patients requiring and receiving orthopedic shoes,
require them to be custom fabricated. Thus what
Dr. Markinson speaks to at least with regards to
shoes is only a small segment of the population;

2) Farm these difficult cases out to those who
are experts. The costs of sending shoes back and
forth will quickly eat away at any profits.
Patient and supplier frustration at the process
may disenfranchise your relationship with the
patient. Farming these out will also allow you to
bill for an e/m each time the patient comes in to
you for an evaluation of their footwear
prescription. This is no different than evaluating
a patient's response to PT or medication you have
prescribed;

3) If you are going to supply custom fabricates
shoes, endeavor to have a cool head and be sure
you, your staff and the patient have a proper
level of expectation. Tell them, this will be the
ugliest pair of shoes you've ever seen or worn,
but at least they will be able to walk with the
knowledge that the shoes are limiting their
potential for further foot problems;

4) Use a manufacturer who will remanufacture or
repair a poorly fitting shoe for free, no
questions asked. Use one who will come to your
office and teach you how to cast and/or to assist
you with a difficult case and one who can provide
customer support for difficult cases, both before
and after casting. There is a very high learning
curve with this product. Be prepared to fail a few
times. Everyone who eventually succeeds has
numerous failures to discuss;

5) Use a manufacturer which has a set price (e.g.
$250 for a pair of shoes), with one pair of
inserts, in particular for those which will be
billed to Medicare;

6) Be sure you understand the coding for the other
modifications; Simply because a third party payer
has a limit on coverage does not mean you
provide the patient with those other modifications
for free (see next);

7) Don't swallow the extra costs for those
modifications Medicare (or other third party
payers won't pay as they are in excess of the two
additional add on codes they will pay for). Those
"extras" are required modifications for a proper
shoe fit and to reduce the patients risk of
developing further issues. Properly educate the
patient on this before you cast. Be sure they
understand their financial responsibilities for
any required add on costs not covered by their
third party payer and of course properly document
this (ABNs, etc.);

8) Ask someone in your office (other than
yourself) who understands the third party policy
to review the documentation you have received from
the MD/DO and your own documentation which may
have required some agreement from the MD/DO. A
second pair of eyes is mandatory for this (even I
have my office staff do this). My patients are
educated that we will not cast, measure or order
any custom fabricated product or even order or
dispense any off the shelf DMEPOS item, until my
office is satisfied we have obtained the required
documentation and that it will be sufficient on
the date the item may be dispensed (which could be
4-6 weeks later).

9) Don't feel pressured to do provide this level
of service for all patients. Just as you "walk
away" from patients who you feel may be poor
candidates for surgical care, do the same with any
DME service, if your gut tells you to do so. Its
just not worth ruining your day (week, month or
year) over a disgruntled patient who your office
staff (or anyone else's for that matter) may not
be able to satisfy.

10) Take the option of being a non participating
supplier. You can accept assignment, take partial
payment from the carrier and balance bill the
patient. Bear in mind you cannot do this, if you
are a participating physician under Medicare
provider and both your supplier and physician NPIs
are linked to the same tax identifier.

11) Follow the Kenny Rogers mantra, know when to
fold em, know when to run away and know when to
hide.

As for the whole therapeutic shoe program, if we
give up on this, you're just sending Medicare a
clear message to continue to go ahead with
undue audits and harassment at a time when many in
the O&P industry are clearly not.

What's next? At risk foot care? Will you give up
that most basic of service when those audits
start? What will be left?

The answer here is to join APMA, AOPA, PFA and
countless other organizations in their lobbying
efforts to resolve this issue by way of the two
chief pieces of legislation before Congress (HELLP
act and the AIR Act Medicare DMEPOS Audit
Improvement and Reform (AIR) Act of 2014). You can
find more information on this on the APMA website.

Paul Kesselman, DPM, Woodside, NY