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06/13/2015
RESPONSES/COMMENTS (MEDICAL-LEGAL)
RE: Is it Legal to be Charged for an EMR I Purchased After I Stop (Richard A. Stanley, DPM)
From: Elliot Udell, DPM
Dr. Stanley's scenario underscores that doctors using EHR systems where the data is stored "in a cloud" should make paper back-ups of patient records.
Many doctors lulled into EHR because of stipends for making "Meaningful Use" are becoming disenchanted because of audits, complex time-consuming systems, and difficulty satisfying the requirements at upper levels. Hence the pool of doctors buying these programs might shrink, causing many of these vendors to go bankrupt. The government regulates and taxes the companies that make and sell EHR software. Why it did not place a requirement on these companies that protect the interest of doctors and their patients is anyone's guess. Be it as it may, we have to protect our patients and ourselves from losing their records. The only way is to keep a paper back-up in addition to what is "in the cloud."
Elliot Udell, DPM, Hicksville, NY
Other messages in this thread:
02/13/2024
RESPONSES/COMMENTS (MEDICAL-LEGAL) - PART 1
From: Farshid Nejad, DPM
We use Elavon. They have a reverse fee program. They charge the customer the credit card fee. We inform the patient of the fees and offer other payment options. We get charged a monthly flat fee for their equipment. We have saved thousands of dollars in credit card fees.
Farshid Nejad, DPM, Beverly Hills, CA
01/10/2024
RESPONSES/COMMENTS (MEDICAL-LEGAL) - PART 2
From: Elliot Udell DPM
Dr. Roth says it all when he states that in his state, California, podiatrists are allowed to perform thigh biopsies for the sake of diagnoses. He also feels that if podiatrists take training, we should be capable of doing spinal implants to control lower extremity pain.
Dr. Roth is correct when he says that DPMs are more than capable of doing a spinal implant and thigh biopsy, with proper training. Most of us do far more intricate surgical procedures on the lower extremity. The major issue for all podiatrists is that we need not forget that our scope of practice is governed state by state, not by capability but by anatomic restrictions. We can and should do a biopsy of a suspicious lesion that presents on the foot. We legally cannot biopsy that same-sized lesion if it presents on the patient's back even though it would be essentially the same procedure.
The bottom line for all of us is that before doing any procedure which is above the lower extremity whether it be a thigh biopsy, spinal implant, or whatever, we must check with our local state authorities to ascertain whether that particular procedure is within the scope of our practices in the state where we practice.
Elliot Udell, DPM, Hicksville, NY
01/10/2024
RESPONSES/COMMENTS (MEDICAL-LEGAL) - PART 1
From: Michael Moharan, DPM, Judd Davis,
I agree with Dr. Lloyd Bardfeld. It’s disheartening to hear about the challenges faced by podiatrists in that hospital. The historical perspective you provided underscores the progress made in integrating podiatrists into the medical staff. Your suggestion to address the issue through a meeting with the hospital CEO and involving the APMA, if needed, seems like a proactive and reasonable approach to resolve the situation.
Michael Moharan, DPM, Norwood, MA
Discrimination is still rampant against podiatrists and will continue to be that way as long as we allow it, and in my opinion, as long as we have DPM behind our names instead of MD or DO. In my city, the same thing happened over ten years ago. Taking call without pay was forced upon the podiatrists at the city hospital which has a tremendous amount of uninsured, indigent, pro bono care. The hospital decided to pay all specialties for call there, EXCEPT podiatry, due to the tremendous burden, but would not let us out of our call obligation. Talk about discriminating! This led to an expensive lawsuit and ended with most podiatrists resigning privileges at the hospital. The hospital went over a year without any podiatrist and their amputation rate skyrocketed to the point they were forced to hire 2 podiatrists to take on...
Editor's note: Dr. Davis' extended-length letter can be read here.
01/09/2024
RESPONSES/COMMENTS (MEDICAL-LEGAL) - PART 2 B
From: Allen Jacobs, DPM
I am hopeful that the comment by Dr. Roth, in which he suggests that he would place a spinal cord neuromodulator in a patient with foot or ankle neurological pain, was submitted in humor. If a patient has a drop foot from L4-L5, would he perform a decompression surgery with fusion? What about an anterior cerebral artery aneurysm affecting only the leg and foot, or an aortic aneurysm causing blue toe syndrome or digital infarction? Is Dr. Roth prepared to treat potential complications such as spinal hemorrhage?
By the way, Dr. Roth, I suspect the placement of a spinal neuromodulator may not be comparable with your no insurance cash-only practice you profess to have mastered. You completed a non-ACGME approved podiatry residency, which you believe provided you with adequate training to place anything in a spinal cord? Please tell us you were joking.
Allen Jacobs, DPM, St. Louis, MO
01/09/2024
RESPONSES/COMMENTS (MEDICAL-LEGAL) - PART 2 A
From: Richard J. Manolian, DPM
Assuming you can do a thigh biopsy in California, is that the best place to do a biopsy for diagnosis of peripheral neuropathy? The answer is no. Next question is when you implant this device, completely out of the scope of your practice, will your malpractice carrier cover you? The answer is no.
Again, I ask when you post such things, why would a patient pay out-of-pocket for this in your office when an actual pain specialist or neurosurgeon will be covered by their insurance? The answer, well you get it by now. If I’m wrong, somebody please elucidate!
Richard J. Manolian, DPM, Boston, MA
01/09/2024
RESPONSES/COMMENTS (MEDICAL-LEGAL) - PART 1 B
From: Lloyd Bardfeld, DPM
I find this post extremely upsetting. There is no place for this aggressive negative activity in our profession today. I question both the legality as well as the willingness of the few podiatrists to choose to remain on staff of the facility. I was the first resident at Peninsula Hospital Center in 1970. At the time, there were no surgical privileges for podiatrists and they were part of the adjunct staff. Surgical privileges opened up and soon after, the bylaws were changed, making us officially part of the medical surgical staff.
Similarly at St. John’s Episcopal Hospital in Far Rockaway New York, where I started podiatry, things went from podiatrists not being allowed to be members of the medical board to me being president. These achievements did not come easy. It required us displaying our professionalism and not accepting being treated as secondary citizens. As we are all aware, podiatry is now more than ever not only a crucial medical profession, but an extremely lucrative addition to any hospital. We as a profession absolutely cannot accept situations like this.
I suggest a member of our profession in the area of the hospital request a meeting with the CEO of the hospital and discuss the situation and if possible settle it amicably. If that does not achieve results, the APMA must get involved, and if necessary, pursue legal action against the administration.
Lloyd Bardfeld, DPM, Far Rockaway, NY
01/09/2024
RESPONSES/COMMENTS (MEDICAL-LEGAL) - PART 1 A
From: Shashank Srivastava, DPM
Was this change made to any other sub-specialties? If you opted to have a status that does not have clinical privileges, is this really an issue for you? I would wager that the legality of this would be based on state statutes. That all said, the hospitals usually can make a requirement for active utilization of the facility in order to maintain credentials, but it generally should not have specialty specifics. Generally, call taking cannot be "forced" but utilization minimums can be required. Also, I would implore you to reach out to your state APMA component.
Shashank Srivastava, DPM, Rockville, MD
05/13/2023
RESPONSES/COMMENTS (MEDICAL-LEGAL) - PART 1B
From: Robert Kornfeld, DPM
You see what lurks in the fine print of your contracts? My advice is to go to a direct-pay practice with a strong niche. This insanity has to stop!
Robert Kornfeld, DPM, NY, NY
05/13/2023
RESPONSES/COMMENTS (MEDICAL-LEGAL) - PART 1A
From: Jack Ressler, DPM
When you receive a request from Ciox, calculate the number of patient requests and multiply it by the amount of money per chart your office has set. Send them an invoice and move on. You will not likely receive payment and it had been my office policy not to send charts requested by Ciox until payment is received.
I retired a few months ago, but was never cancelled from any insurance company for not sending charts to Ciox until they send payment. This has been ongoing for several years. Your obligation should be to Medicare which is being completely ripped off by Ciox and other companies, which has been documented in previous posts.
Jack Ressler, DPM, Boca Raton, FL
05/05/2023
RESPONSES/COMMENTS (MEDICAL-LEGAL) - PART 2
From: Michael M. Rosenblatt, DPM
I recently read on PM News that a "training course" is now required by DEA for prescribers to get registered or renew. I wonder if one of you can respond about this "training" who has experienced it. I don't want to jump to conclusions, but I assume that most of it is delegated to describing the "craftiness" of addicts' attempts to get prescribers to get them what they want. The rest of the experience is most likely used to demonize prescribers and make them feel "responsible" for the epidemic of drug abuse. But I could be wrong. What I would rather suggest more appropriate is for DEA to explain why they do not make more of an effort to prevent illegal drugs from the Southern borders entering the US.
Also, I would like DEA to make an effort to control drug access to the very large cadre of homeless populations in various US cities. DEA turns a blind eye to this. It is much easier to demonize prescribers. I don't want to make this a political discussion, because addictive drugs do not just affect one political group.
But I have a feeling that if a prescriber makes a public comment like this, they can "expect" the DEA to come down on them. So, if you prefer not to respond, I don't blame you. They can try to retract my DEA registration, but I have the freedom to write because I have none. There are some advantages to retirement. Free speech may be one of them.
Michael M. Rosenblatt, DPM, Retired, Henderson, NV
05/05/2023
RESPONSES/COMMENTS (MEDICAL-LEGAL) - PART 1
From: Paul Kesselman, DPM
I have made it no secret that while there is an obligation to respond to the requests, there is no requirement to submit charts at no charge. Here are some things you need to do:
1) Get rid of the dinosaur fax machine. There are methods by which to receive faxes directly to your computer. So no ink, no paper. You can do an Internet search to find a myriad of companies which charge a minimal amount based on the number of pages. (e.g. $10 for 100 pages incoming and outgoing). Let Ciox send as much as they want. Depending on the service you choose, you may also be able to block incoming faxes based on the phone...
Editor's note: Dr. Kesselman's extended-length letter can be read here.
05/04/2023
RESPONSES/COMMENTS (MEDICAL-LEGAL) - PART 1B
From: Steve Abraham, DPM
Ciox requests can take 10 minutes to respond to. Ciox presents a portal to upload chart notes. Your EHR should be able to save a chart note in PDF format. Make a folder on your desktop, and save all the .pdfs to the folder. Log onto the portal and upload all. It is a very quick and efficient way.
After you are done, delete the folder from your desktop to comply with HIPAA rules.
Steve Abraham, DPM, NY, NY
05/04/2023
RESPONSES/COMMENTS (MEDICAL-LEGAL) - PART 1A
From: Jessica Cortes
We also have been subject to Ciox Health's harassment. We fax back an invoice requesting $30 per chart, citing California Health & Safety Code section 123110 - allowing the fees for processing and preparing records.
We instruct staff to not answer any questions until payment is received. We fax the same letter each time we receive the same request. Payment is received each time. It won't stop the requests but at least we're being fairly compensated for it.
Jessica Cortes, San Francisco, CA
04/26/2023
RESPONSES/COMMENTS (MEDICAL-LEGAL) -PART 1B
From: Ivar E. Roth DPM, MPH
I would like to thank PM News for informing me that I really do not need a DEA number. I very rarely prescribe opioids and there are ways around that. In addition, this MATE training is just one step too much. They should require that training for professionals who really write for narcotics. The rest of us would be exempt. At any rate, I will not be renewing my DEA license and will save the $1,000 which I will donate to a podiatry cause.
Ivar E. Roth DPM, MPH, Newport Beach, CA
04/26/2023
RESPONSES/COMMENTS (MEDICAL-LEGAL) -PART 1A
From: Michael Brody, DPM
All providers who register or renew their DEA registration beginning June 27, 2023 must take the 8 hour course. Here is a link to the letter from the DEA.
"Beginning on June 27, 2023, practitioners will be required to check a box on their online DEA registration form—regardless of whether a registrant is completing their initial registration application or renewing their registration—affirming that they have completed the new training requirement." CME Online offers a course that meets this requirement.
Disclosure: Dr.. Brody is CEO of CMEonline.com
Michael Brody, DPM, Commack, NY
01/17/2023
RESPONSES/COMMENTS (MEDICAL-LEGAL)
From: Paul Kesselman, DPM
It’s no secret that many doctors have some very strong opinions which criticize the Medicare Advantage Plans. Low pay, providing prior authorization and then denying the claim, illegal data mining and marketing campaigns which promise the sky; these are just only a few of the issues we should be screaming about when dealing with these companies. It’s about time that CMS cracked down on the advertisements and the dollars these companies spend on those commercials. And in 2023, they will need to have CMS vet those commercials prior to allowing them to air.
A great way for CMS to get some dollars back is to charge the Medicare replacement carriers money to review their marketing campaigns at Fair Market Value and tax the revenue they pay to the media (have the insurance carrier pay the tax) for these commercials. And how about some additional transparency with how much they paid...
Editor's note: Dr. Kesselman's extended-length letter can be read here.
01/16/2023
RESPONSES/COMMENTS (MEDICAL-LEGAL) - PART 1B
From: Kristin Happel
The amount of "risk adjustment" chart requests is always commensurate with how many patients you have seen in the previous year with those particular MA plans. You see 50 patients with that MA plan, you get 50 chart requests. At least that has always been my experience. I went from charging $25 a chart in previous years to $50 a chart for 2021 charts. In 2023, I will up that to $75 a chart for 2022 charts.
CIOX or whoever is requesting the charts always pays what I invoice them for BEFORE I send the records. And yes, I have reviewed my insurance contracts to make sure this is legal. Bottom line is this: these MA plans are trying to get more money from Medicare, by doing these "risk adjustment" chart reviews. While I guess that is their prerogative, it is MY prerogative to make them pay for that "info". I can only hope at some point they realize they are paying more out for their "precious info" then they are taking in for it.
Kristin Happel, Podiatry Biller, Chicago, IL
01/16/2023
RESPONSES/COMMENTS (MEDICAL-LEGAL) - PART 1A
From: Robert Kornfeld, DPM, Michael Orosz, DPM
Dr. Williams, like others, will have his records "reviewed" so that insurance companies can come up with a "valid" reason to reject claims and demand refunds. I went through this many years ago. When money was demanded back from me by Medicare (after a review of 80 charts), I went to a lawyer, had my assets "protected", and then opted out of insurance and Medicare. That was 23 years ago.
Every day, I thank insurance companies for giving me grief over my extremely valuable protocols that have helped thousands of patients. I have no more stress and I work smart, not hard. The difference now is that my patients pay me and no insurance company gets to "review" my records.
Robert Kornfeld, DPM, NY, NY
We have had a few requests of around 75 patients. We also charged for each chart and refused to release the records until payment was received. We do get requests for a single patient only so it balances out.
Michael Orosz, DPM, Cedar Rapids, IA
12/07/2022
RESPONSES/COMMENTS (MEDICAL-LEGAL) - PART 1B
From: Paul Kesselman, DPM
Several years ago, I was confronted with a steep hike in DEA registration fees and my discontinuation of full-time practice and going non-surgical. At first, I received many calls from insurance companies insisting that I must have a DEA number or provide some alternative to providing narcotic prescriptions to my patients. At the advice of others, I relented and paid the fee, simply to get the insurance companies off my back. Three years later, when another steep hike was instituted, I had enough. I informed the insurance companies I would refer the patients either to another podiatrist in the area who saw patients requiring narcotics and who was willing to do so, or I would refer them to the ER for podiatric care. The letters stopped and the requests for providing a DEA number, even from CAQH, stopped.
Before I took this step, I called my state board of pharmacy to be sure that no DEA number was required in NYS to prescribe non-narcotic medications. What I was told was that there was a short list of non-opioids, including Tramadol and Lyrica, which did require a DEA registration, but for the most part, non-narcotic medication prescriptions do not require the practitioner to be registered with the DEA. I also called my pharmaceutical suppliers who told me the same thing.
My suggestion is for you to check with the NJ State Board of Pharmacy and also check with a few of the top insurance carriers you participate with prior to making any decisions, and proceed accordingly.
Paul Kesselman, DPM, Oceanside, NY
12/07/2022
RESPONSES/COMMENTS (MEDICAL-LEGAL) - PART 1A
From: Elliot Udell, DPM
It is not mandatory in most, if not all, states to have a DEA number. If you are not prescribing controlled substances, why give the government a thousand dollars to renew the number? Most insurance companies will not mind, but many will require you to provide the name and number of a colleague who can prescribe controlled substances if your patient needs it.
The only other problem is that a small number of companies such as Clint Pharmaceuticals will not do any business with you unless you have a DEA number. With pressure on doctors to limit the prescribing of controlled substances, these small niche companies are cutting their noses to spite their faces by not even selling "gauze" to a doctor who does not have a DEA number.
Elliot Udell, DPM, Hicksville, NY
08/10/2022
RESPONSES/COMMENTS (MEDICAL-LEGAL)
From: Michael King, DPM
This note is excellent. although distressing to read. Targeted audits are not to be taken lightly and their advice about seeking counsel is spot on. PICA has excellent ADC (administrative defense coverage) in all their policies. Don't go this alone. Get expert assistance. This situation of the targeted audits is ramping up substantially as of late. It is critical to review one's LCD/LCA for all services from the local MAC and make sure the EMR and macros within are complete, comprehensive, and consistent with both the service rendered and the details needed from the LCD.
Michael King, DPM, Nashville, TN
06/01/2022
RESPONSES/COMMENTS (MEDICAL-LEGAL) - PART 1B
From: Clifford Wolf, DPM
State license laws that address best practices for prescribing medicine to treat gout fall into grey areas. Some doctors are comfortable and confident to therapeutically treat, others are not. For both groups, do you possess mastery of nephrophysiology and internal medicine to defend efficacy of your treatment? If you do, please help your patient.
Clifford Wolf, DPM, Oceanside, CA
06/01/2022
RESPONSES/COMMENTS (MEDICAL-LEGAL) - PART 1A
From: Jim Shipley DPM
It’s my understanding that once licensed and practicing, the final say on what can be done in my practice and what can’t be done is decided upon by the State Board of Podiatry in my state. For me, that’s North Carolina. Please give me some feedback on this possibility: Why can’t our local state boards begin training and certifying individuals at our state conferences to treat hyperuricemia? We want parity.
If the schools won’t train us for parity, why not begin our parity training at the state level? I would happily take classes and take exams showing my ability to comfortably prescribe uric acid lowering medications. On the same train of thought, I would gladly accept the training and certification to take on the burden of the medical management of blood sugar levels in my patients as well.
Our predecessors fought long and hard for our scope within our state. I’m ready to continue the advancement. Showing we’re trained to advance is the first step. Please give me your thoughts and wisdom on this topic.
Jim Shipley, DPM, Mt. Airy, NC
05/31/2022
RESPONSES/COMMENTS (MEDICAL-LEGAL) - PART 1B
From: Joe Agostinelli, DPM
I think that we all should be able to diagnose and treat a foot/ankle suspected or known acute gout attack to a joint. For example, aspiration of the great toe joint, synovial fluid crystal analysis to establish actual gout is a common occurrence in clinical practice. As we well know, the fluid aspirated is very often actually seen as gout with tophi. Then, injection of local anesthesia/steroid injection into the joint is appropriate. Rx for indocin, 5 day course, or Medrol dose pack, if recurrent attack, is also appropriate and in the realm of our practice, as short-term acute management.
Laboratory orders for uric acid blood level and referral to PCM is also a prudent plan after your initial gout attack diagnosis and in-office treatment. I agree with Dr. Jacobs and those who do not recommend continued medical management of "hyperuricemia". In my clinical experiences in a multi-disciplinary hospital-based, clinical USAF practice, and then in an orthopedic surgery group practice. This approach has been accepted well by PCMs, rheumatologists, nephrologists, internal medicine docs to whom the patient is referred. I can assure you that those specialists are very happy to have a joint aspirate confirming gout rather than just elevated uric acid levels. We all are aware of patients who say, "I have gout," but there is never a definitive joint aspirate confirming that diagnosis!
Joe Agostinelli, DPM (Retired), Niceville, FL
05/31/2022
RESPONSES/COMMENTS (MEDICAL-LEGAL) - PART 1A
From: Elliot Udell, DPM
This conversation on the prescribing of urate-lowering medications is not a new one, with many saying yea and others saying nay. The crux of the controversy is whether treating hyperuricemia is addressing a systemic condition or a local manifestation of gout. Those who argue that it’s systemic are quick to equate it with the management of diabetes. There are distinct differences between the two ailments. For example, if a patient presents with acute gout affecting an elbow or has hyperuricemia with no clinical manifestations, treating it or even telling a patient not to have it treated would be out of scope for us.
On the other hand, if a patient has pedal manifestations of gout and there is a direct link between the symptoms and hyperuricemia, then it...
Editor's note: Dr. Udell's extended-length letter can be read here.
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