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From: Robert Scott Steinberg, DPM


I have to call Dr. Fullem, on the appearance of bias, when it comes to him recommending Hoka shoes. I have found them very unstable. They do have the unwanted tendency of excessively straining the calf and the Achilles. Because they are unstable, there is unnecessary overuse of certain muscles. Is there anything worse than getting or treating Achilles tendinitis if you are a runner? His use of the word "old", in an attempt to cast doubt on the proven protective properties of the classic 10-12mm drop, stability running shoe, further exposes his bias. Once runners get past the gimmicky nature of fad running shoes, they see the foolishness of some trends.


Robert S. Steinberg, DPM, Schaumburg, IL

Other messages in this thread:



RE: The Importance of Challenging Medicare

From: Amy Schunemeyer, DPM


So, I noticed that my Medicare allowable was less than the Novitas website posted allowables for my claims coming back for 2018. There is a Novitas mistake that they were following the WRONG fee schedule up to 2/23/18, and they are working on resubmitting corrected claims. This is one problem fixed. 


And, I notice that the increased payment adjustment is in the form of a positive ($xx.xx) adjustment on our EMRs. This is quite a software accounting nightmare. How are others handling this? These are a few of my questions because I am NOT receiving increased payment from the many, many....


Editor's note: Dr. Schunemeyer's extended-length letter can be read here.



From: Simon Young, DPM


With 3-year residencies programs, a publishable, even collaborative, paper should be a requirement for graduation.  So much research can be done over their tenure as residents and they should recruit their podiatric director, administration, and other specialties in neurology, orthopaedics, ER, medicine, endocrinology, dermatology, podiatry, rheumatology, infectious diseases, biomechanics, physical therapy, etc. What a plethora of topics available to be researched and put us on the map. We need to show the other professions that foot pathology is more than nails and callosities.


When I was a residency director, it was difficult to impossible to get my residents to publish or offer research ideas. I did have the cooperation of administration and some specialties but not all. The ER was willing so I was able to get one research paper published.


NYCPM has a relationship with Ireland Podiatry School and they present more research than our graduating 3-year residents. What are they doing right?


Simon Young, DPM, NY, NY



RE: Lack of Podiatric Authors in Our Journals (Joseph Borreggine, DPM)

From: Amol Saxena, DPM


There are many reasons for the lack of DPM-produced research and more non-DPMs publishing in our journals. 


Most podiatric students and residents are not required to actually complete written and publishable research during their training. There may be less "perceived value or need". As I interview fellowship candidates, I am able to see how much research they are actually required to complete. Most are case studies. There was a time where podiatrists were trying to document their cases and show the pathology they were capable of seeing. Publishing was the only way to...


Editor's note: Dr. Saxena's extended-length letter can be read here.



From: Bret M. Ribotsky, DPM


I have been consulting and advising for the past 18 months in the buying and acquisition market for medical dermatology practices. While I have not specifically worked with the DPM market, the foundations and principals from the hedge funds and private equity people are similar. It’s all a function of EBITA (Earnings before interest, taxes, and amortization. EBITA refers to a company's earnings before the deduction of interest, taxes, and amortization expenses). 


In simple terms, it’s the PROFIT left over after you have removed your ownership from the practice and paid someone (or you) to do the work you have done. For example, if you're a single practitioner and your practice gross is...


Editor's note: Dr. Ribotsky's extended-length letter can be read here



From: Brian Kashan, DPM


I just read the posting by Name Withheld, about how he would choose to open an office next to an older practice instead of purchasing an existing practice. Although the circumstances he describes, with the sudden passing of a doctor is different than the more common scenario of a retirement, there are several similarities. If the practice has been a successful practice and is valued correctly, it should be an attractive opportunity for someone to acquire. 


There are several factors that I feel are being overlooked in the mindset of Name Withheld. Firstly, it is much easier to get a bank loan when...


Editor's note: Dr. Kashan's extended-length letter can be read here.



From: Janet McCormick, MS


As per dental hygienists practicing without supervision, I would truly like to know where that is? I'm thinking that somewhere in the background there is a "dental supervision" requirement, possibly similar to aesthetic spas level peels etc. as long as they are "supervised by a physician." Many of these medical supervisors are not on site, but there is a responsibility there, and they must be within a set distance. And they are financially involved in some way. 


I find it doubtful that dental hygienists would escape the supervision of dentists fully. The dental associations are very active in the legislative processes and...


Editor's note: Ms. McCormick's extended-length letter can be read here.



From: Eddie Davis, DPM


Dr. Borreggine has concerns about the implication for podiatry caused by expansion of ARNP scope. Dr. Herbert, in his response, related an interesting story about a podiatrist who later became a family practice physician, but his hospital did not offer him privileges for foot surgery. We should not view the efforts of other health professions to expand scope as a threat to podiatry. We should, instead, attempt to better define our scope of practice. 


Podiatrists, relative to training hours, have the narrowest scope of practice of any health profession. APMA believes that we need to emulate the allopathic model and increase residency training time. How do you tell a prospective podiatry student that he/she will be offered training equivalent to an orthopedic surgeon but that the scope of practice can only be less than 15 percent of that of an orthopedic surgeon and then tell that person that he/she may not be able to call themselves a physician?


The dental profession has figured out how to maintain a degree as a “limited licensed practitioner” and make it work. We either emulate the model of dentistry or move toward providing the MD degree. Standing in the middle of the door is not advisable because the door will keep hitting and bruising us.


Eddie Davis, DPM, San Antonio, TX



From: Name Withheld (TX)


To echo Dr. Borreggine’s concern, I am currently sitting for my boards in both foot and rearfoot/ankle case reviews. I have the most recent training with the PMSR with the RRA certification. I had my share of failures with the CBPS portion of the exam and I found after speaking with the board that it was not due to my intellectual abilities to reason or make good decisions; it was how I was taking the test which was not explained at the time that I took that portion of the exam. After speaking with them, a video was posted regarding my specific issues that I experienced, which leads me to believe that this was a common problem among candidates. 


Once I passed my CBPS portions, I sat for my case review. This was the most frustrating aspect of the process. I was failed based on...


Editor's Note: This extended-length letter can be read here



RE: ABFAS Board Exam Pass Rate is Disparaging (Joseph Borreggine, DPM)

From: Name Withheld


I graduated from a 3-year residency program in 2013. I passed all my NBPME exams the first time and I passed the ABFAS qualifying exams the first time. Then I bought a non-surgical practice in a small town and set to work. I have spent 4 years building up my case volume and then was able to sit for the exam. I failed both the case studies and the computer-based examination. My hospital says I have to be board certified in a 5 year window. I have one more shot at it in 2018. 


During residency, ABFAS lets you take yearly practice tests to be prepared for the qualifying exam, but not after residency. So, I went 4 years not taking a practice test and then finally being able to sit for it and failing it (They used to make you wait until your case volume was built up prior to taking the computer-based exam). Just this year, I heard that ABFAS is allowing candidates to...


Editor's note: Name Withheld's extended-length letter can be read here.  



From: Kenneth T. Goldstein, DPM


I totally agree with Dr. Udell. Years ago, when a patient didn't want to pay a bill, they threatened to sue. Now-a-days they threaten to post a "nasty review"(because it will cost them money to hire an attorney). The fact that this patient not only wanted the fees removed, but also a DISCOUNT! is absolutely ridiculous. Should you give in, this person sounds like they will write the negative review anyway and say to themselves - "Gotcha".


You have done all of the correct manners and given more than enough time for this patient to pay. At this point my answer would be - It is out of my hands and the collection company has control of your account.


Kenneth T. Goldstein, DPM, Williamsville, NY



From: Jarrod Shapiro, DPM


I'm writing in response to Dr. Sherman's comments about online CME. I agree with his comments and support the opinion that online CME should be unlimited in all states. Simply put, the content and delivery is the same, the requirements for proof of viewing is higher than at live conferences, and this delivery method is appropriate for adult learners. The various online CME available allows a physicians to receive rapid answers to topical clinical problems using on-demand education services. This format is innovative and able to change with developing technologies. Allowing online CME to flourish is equivalent in the medical community to the progress of the Internet itself. This system must be allowed to develop.


Disclaimer: Dr. Shapiro writes the column Practice Perfect for PRESENT e-Learning Systems.


Jarrod Shapiro, DPM, Pomona, CA



From: Bret Ribotsky, DPM


I’ll take the counterpoint to my friend and Boca Raton neighbor, Dr. Sherman. Live CME events are best. Not only have I had the opportunity to have lectured in 49 of the 50 states and many 15 different countries, but I have also been the patient for multiple foot operations. For the months after my accident, I spent many months in rehab, unable to walk, and did many online classes. I collected online training certifications in real-estate, insurance, financial planning, securities series 7, 63, and a bunch more. But... there is nothing as good as live learning. And as a physician, there is so much more to learn at a seminar than what is learned in the lecture hall. I have learned so much in the hallways, and at the bar from my colleagues. Meet the Masters was started 8 years before my injuries, with the idea that learning outside of the lecture hall was priceless.  


I do enjoy online events, but I would hate to miss the yearly get togethers to learn from and with others. As a patient, I know the difference between great and outstanding care; that it comes from those with exposure to many viewpoints which only a live event can deliver.  


Bret M. Ribotsky, DPM, Boca Raton, FL



From: Dennis Shavelson, DPM


I am a 71 year old practitioner and find myself more and more successful attracting millennial patients by marketing how I practice.

  •  I offer holistic cures, not just tunnel vision Band-Aid care.

  •  I offer care of treatable underpinning pathology (medical, biomechanical and   kinesiological).

  •  I practice Prevention, Performance Enhancement and Quality of Life Upgrading.

  •  I offer more seamless office visits and availability in the cloud.

  •  Rather than state that I treat everything for every foot, I market niche compartments of diagnosis and care (biomedical engineering and ugly toenail cures).

  •  I have hardship and sliding scale fees available.  

Dennis Shavelson, DPM, NY, NY



From: George Jacobson, DPM


Since this topic has come up again, I would like to remind everyone of a posting that I wrote on 03/05/2016. You can search it in the PM News archives. In a nutshell, here is the main excerpt, "We received a letter from Palmetto GBA stating that they have received information from the National Supplier Clearinghouse (NSC) indicating  that we have not billed the Durable Medical Equipment Medicare Administrative Contractor (DME MAC) within the last four consecutive quarters."   


George Jacobson, DPM, Hollywood, FL 



RE: Enough Already with Time-Consuming Chart Requests (David P. Luongo, DPM)

From:  Cynthia Ferrelli, DPM


I have experienced the same problem, so I came up with a solution several months ago that has been working fine. When my office is called for a chart review, we say we will comply but that their reps come to my office, will have to pull all the charts themselves, and find what they need in the chart. We tell them that this is how we do it and we set the guidelines. Set your boundaries. You are paying your staff to do work for you, not for the insurance companies. We seem to do enough of that already.


Cynthia Ferrelli, DPM, Buffalo, NY



From: David Gurvis, DPM


I also have a missed appointment fee. I find the “threat” alone reduces missed appointments. Do I apply the fee uniformly? No. Actually, I hardly ever use the fee unless a patient has been egregious in repetitive missing of appointments. What I find then is that if I apply the fee, the patient goes away. The desired result. They fire me and I don’t have to discharge them!


I don’t have the fee on new patients as it is too difficult to make sure that they understand my policy, but if they miss two appointments, I refuse to take them back. As always, there is common sense. Missing an appointment without a call later is frowned upon more than missing with a call later that indicates the patient is sorry and had a lapse in memory or perhaps a real reason.


David Gurvis, DPM, Avon, IN



From:  Brian Kiel, DPM


I have a different perspective on this issue. Even though it can be aggravating to have no- shows, perhaps you are better without them in the first place. Those who do that frequently will be the ones who will not follow instructions for care, especially post-op or with wounds. I prefer not to have those patients in my practice. Also, another aspect is that we do slightly overbook on purpose and when there are no- shows, which happens every day, it leaves me a chance to "catch up.


Brian Kiel, DPM, Memphis, TN



From: Paul Busman, DPM, RN


I wouldn't require a credit card guarantee. Right off the bat, even before you'd established a doctor-patient relationship, you'd have shown distrust for that new patient. You've also suggested that getting their money is more important than taking good care of them. Missed appointments are a fact of life.


A better way would be to call that potential new patient the day before the appointment and remind them of the date and time, and tell them how much you're looking forward for the chance to care for them. 


Paul Busman, DPM, RN, Frederick, MD



From: Paul Kesselman, DPM


When Medicare Part D first was announced, I was asked to research and write an article on the subject. To my astonishment and much to my chagrin, the pricing of drugs was not set by the government but by private insurance carriers and the industry. This and other issues such as the donut hole, deductibles, etc. have left many seniors in a position of having to choose  food or medicine. 


Many split the doses of medications which may have not been engineered for such a procedure. Some I am told even end up in the ER due to the untoward toxic effects of the resulting...


Editor's note: Dr. Kesselman's extended-length letter can be read here.



From: Bradley Bakotic, DPM, DO


I'm a bit confused by the post related to ENFD by John Hurchik, DPM and some of the subsequent responses, particularly that offered by Elliot Udell, DPM, who seemed to imply that clinical doctors, and their labs, are doing ENFD testing strictly for "massive" financial gain rather than optimal patient care. 


First, let me say that I have been informed that Dr. Hurchik did intend for his note to take the negative tone that it seemed to. Secondly, those that believe that a punch biopsy pays a "massive" amount of money, probably have never done a punch biopsy. The "massive" reimbursement for a punch biopsy is about $85.00. It might buy you...


Editor's note: Dr. Bakotic's extended-length letter can be read here



From: Ed Cohen, DPM


I think if the patient has a good hgba1c, the procedure is safe. The nerve biopsy is slightly more accurate than a Sudoscan. The Sudoscan is a three-minute test where patients step on plates while placing their hands on other plates. I  think the Sudoscan is accurate enough to give you a good diagnosis and has the advantage of not having to treat a biopsy wound. Another great advantage the Sudoscan has is that you can safely run the test on any diabetic patient no matter how high their blood sugar, and the equipment can never cause an infection.


The  patient is usually more receptive to a non-invasive test and the Sudoscan is a good practice builder. The downside is insurance reimbursement, which used to be very good, but has now become a problem in the last few months. In some states, podiatrists are not authorized to use the machine. I have found the Sudoscan a great objective tool to evaluate the effectiveness of my treatments and selling the various nerve food products to the patients can also be a nice revenue generator. Patients also don't mind paying for the test when it is not covered by insurance.


Disclosure: I have no financial relationship to Sudoscan.


Ed Cohen, DPM, Gulfport, MS



From: Dennis Shavelson DPM


Tuesday, there was a fire at Ortho-Rite, my orthotic fabrication and biomechanics cornerstone for 25+ years. Its heart, muscles, and brains - Greg Sands, OP - must process and restore what he has quietly built from scratch. The impact that he has had on the face of biomechanics and orthotics will be recognized while he is doing so.


There is no immediate fix. All involved from the lab to our practices to our patients will be sharing the pain and suffering caused by the shocking event that took place. We will survive and become stronger, wiser, and more successful. I can’t seamlessly transfer my work to a competitor of Ortho-Rite. Greg is the best fabricator of custom foot orthotics from A to Z. Over the years, he has partnered with so many, handling the glitches and snags that exist in the custom foot orthotic marketplace quickly and professionally. His devices outlast and outperform all other labs that I have worked with, visited, and monitored over 40 years. 


In order to help Ortho-Rite get back on its feet (pun intended), until I get a sense of how long it will be before Ortho-Rite will again be open for business, I am holding out. I have under-appreciated the importance of Ortho-Rite in my life until Wednesday. I remain available to assist any colleague or vendor that finds his-/herself in shock and unable to deal with the enormity of this event. Join me in offering a quick and coherent rebirth to Ortho-Rite.


Dennis Shavelson DPM, NY, NY



From: Martin S. Lynn, DPM, Jay Seidel, DPM is an excellent resource, providing options such as email destruction after a pre-determined time.


Martin S. Lynn, DPM, Oil City, WA


I use G Suite. It's the paid version of Gmail, Calendar, and Drive. You can sign a BAA with them and they are HIPPA- compliant. Also, it looks more professional, as you'll have Pricing starts at $5/month per user for 30gb of storage, and for another $5/month, storage is unlimited.


Disclosure: I have no financial interest in Google's products.


Jay Seidel, DPM, Baltimore, MD



From: Jon Purdy, DPM

There are a number of ways to achieve better patient flow in an office. Some are more expensive with installed lights or computerized options within EMR systems. There are less expensive manual colored flags that hang outside patient rooms and used as indicators for what is to occur in that room. I feel tthat the system I have always used in my practice is even more simple and effective. 

I have designed a “task sheet” which is a categorical list of our most common diagnostic and therapeutic procedures, dispensed items, medications, and other “tasks” that I perform. This sits in the chart holder outside the patient room. If it is vertical and backward, I know this is the next patient to be seen. I take it in the room and fill out what I need performed for that patient. My assistants then know to orient the task sheet of the next patient to be seen, from horizontal to vertical.

When I walk out of the patient room, I place the task sheet vertical and forward. The assistants perform and prepare what I have checked off, such as x-rays, injections, medications, and bracing, as I walk into the next room, which has a vertical task sheet. By the time I am done with that patient, the tasks I have marked for the previous patient will have been performed and initialed. I can finish up with that patient and mark any additional tasks needed - and the process continues. Of course all HIPAA compliance is followed, so no patient identifiers are visible. Theoretically, one could see and treat patients without ever having to verbally communicate with the well-trained assistant.

Jon Purdy, DPM, New Iberia, LA



From: Vince Marino, DPM


As I was reviewing ADA Section 1557, I came across this on the HHS website, which I would like others with more knowledge to comment upon. Is it possible that we in private practices might not be considered a “Covered Entity” according to the definition from the Office of Civil Rights, and hence be excluded from section 1557 compliance?


Civil Rights Obligations of Covered Entities - Nondiscrimination laws enforced by the Office for Civil Rights (OCR) prohibit discrimination and require covered entities to provide individuals an equal opportunity to participate in a program activity, regardless of race, color, national origin, age, disability, or (under certain conditions) religion or sex.


What is a Covered Entity? - A Covered Entity is any entity that receives federal financial assistance from the Department of Health and Human Services or is covered under Title II of the Americans with Disabilities Act as a program, service, or regulatory activity relating to the provision of health care or social services.


How do you know if you are not a Covered Entity under OCR jurisdiction in its enforcement of nondiscrimination laws? If you receive some type of federal financial assistance from another federal department or agency but it does not include any HHS assistance, you are not a covered entity under OCR’s jurisdiction. You may also not be such a Covered Entity if you are a healthcare professional who accepts only Medicare Part B insurance payment. (Bold and Italics added by me.)


Vince Marino, DPM, San Francisco, CA