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08/04/2016 James Koon, DPM
Getting CMS to Provide the Correct Advice on RFC (John Moglia, DPM)
Like many, I am tired of this complaint. It is really, really simple: YOU are the doctor interpreting the LCD. YOU know what will and will not get paid by insurance. YOU know what is and is not medically necessary. YOU are responsible for the repayments if Medicare deems the service non covered and you submitted a claim for covered services.
If the patient is unhappy that their routine foot care is not covered then ask them the following question: "Mrs. Jones, are you asking me to commit fraud?”
“But my other doctor gets it covered!” Response: "Then go back to that other doctor.” (Don’t be naive: sometimes patients say that just to see if you will buy it)
“But if you code it right it will get covered!” Response: "Sure it would, but Mrs. Jones, are you asking me to commit fraud?”
“But I’m DIABETIC!!!!!” Response: "Great. And really great that you don’t qualify. That means you’re a “healthy diabetic” Aren’t you happy to hear that?"
“I forgot that I’ve been having pain in my arch. Can you cut my nails while I’m here?” Response: "Yes, after I workup and treat your covered problem. Then we can do the non covered work" (Surprisingly, their “pain” seems to go away immediately)
“I want my FREE shoes!” Response: "Mrs. Jones, first of all they aren’t free. Taxpayers pay for them. And you don’t qualify because you don’t have terrible circulation on MY examination (not the patient’s), part of your foot cut off, a foot deformity, calluses and sensation loss or ulcers. Thank God you don’t."
“Then how come my other doctor gets them for me every year?” Response: "Well, Mrs. Jones, you’re OTHER doctor is a fraud. Medicare is very clear on what they do and do not cover and you don’t meet the criteria. Sorry. You CAN purchase them for cash if you want." (at that point they usually say, “they’re too heavy”)
People, please. Are you hurting so much that you are willing to defraud the government instead of doing what’s right? Are you really willing to do the necessary documentation for a service when a non covered service is just a few lines and no MU/PQRS/MIPS/MACRA/VBM/etc, etc?
My practice is 50% routine care. Of that, only about 10% meet the criteria for medical necessity. The rest pay cash. And they pay gladly because I’m good, I don’t hurt them, my office is nice and very clean, I wear a tie and doctor jacket, my girls are nice and wear uniforms and I act professionally. It’s not rocket science.
Trust me, I wish none of it were covered. Cash is King. I charge on three different levels of care: easy, not so easy and hard.
I don’t argue with patients anymore. If I say it’s not covered, then it’s not covered in MY office. Go somewhere else and get what you want. I’m not the only game in town. I know and follow the Medicare rules to a “T”. There is no compromise and there never will be. Why would you want to anyway? Medicare IS going to catch you. I choose to stay out of trouble instead of having to get out of trouble.
James Koon, DPM, Winter Haven, FL
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08/03/2016 Bryan C. Markinson, DPM
Getting CMS to Provide the Correct Advice on RFC (John Moglia, DPM)
RE: Getting CMS to Provide the Correct Advice on RFC From: Bryan C. Markinson, DPM
This problem goes way beyond having CMS employees telling Medicare patients wrong information about coverage policy. The IRS is famous for giving wrong information on tax rules to the public., and I am sure most gov’t agencies have similar deficiencies in transmitting accurate information to the public who are simply trying to understand and comply with the rules.
The routine foot care issue, however, is plagued by so many other confounding problems. For example, the right for regional Medicare carriers to interpret federal CMS guidelines independently. While being on warfarin is a recognized risk factor and acceptable for routine foot care in one part of the country, the same patient’s care is medically unnecessary (and potentially fraud and abuse) in another.
While the American Diabetes Association recommends professional foot care for toenails and keratotic lesions for diabetics, they take no position and offer no support on coverage for those diabetics who do not qualify. However their public service advice cannot be interpreted any other way except that it applies to everyone who is diabetic, which is not the case as we all know.
Geriatricians, diabetologists, primary care physicians, etc. are happy to refer their infirmed patients who can no longer do self- care for a myriad of medical reasons, but are very poorly versed in coverage rules and often shocked that a person with dementia, Parkinson’s, morbid obesity, s/p total hip replacement, etc.and foot pain are not covered for these services. To get $400.00 worth of diabetic footwear and inserts, you simply need to be diabetic and have a hammertoe, yet a patient with profound sensory loss due to idiopathic neuropathy with ulceration is out of luck! I can go on and on.
As the future of healthcare evolves into “population management” as opposed to “patient care,” and as of 2017 when you will be evaluated and paid (or not paid) for a “happiness” quotient, you may just find yourselves offering ree routine foot care for everyone, to preserve the “happiness” part of your income while your foot and ankle reconstruction services and diabetic limb salvage services become financially impossible to provide.
Bryan C. Markinson, DPM, NY, NY
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