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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

“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,

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

Other messages in this thread:

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
Rockwood Programs