June 12, 2006 #2, 603 Editor-Barry Block, DPM, JD

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Othotics Can Benefit Golfers: NY DPM

While golf is not considered a rigorous sport, the physical act of repeatedly swinging a golf club in practice and on the course can cause problems for our feet. Orthotics can easily be made for golf shoes. An orthotic is an arch support that goes into a person's shoe. Podiatrist Dr. Stacey Sarmiento said, "What an orthotic does, it doesn't create an arch. It helps position your feet where your foot needs to be, to properly function."

"Especially with golf, having joints out of alignment, with the repetitive walking, the repetitive motion, going side to side with their swing, you can develop arthritis over the years," Sarmiento said.

Source: Diana Palotas, News 10 Now (NY) [6/10/06]

NYSPMA Meeting Report

The 110th Annual Meeting of the New York State Podiatric Medical Association was held this weekend in Saratoga Springs, NY. Of note was a resolution passed, forming a special committee to investigate affiliation with local and state medical society groups.

Election Results were as follows:

President: Scott Altman, DPM
President-Elect: Robert Rampino, DPM
Vice-President: Roy DeFrancis, DPM
Treasurer: Mark Schilansky, DPM
Board of Trustees: Gary, Stones, DPM, Robert Russo, DPM, and William Pierce, DPM

Query: Nothing to CROW About

In mid-May, I cast a Medicare patient with Charcot for a CROW (Charcot Restraint Orthotic Walker), and sent the cast impressions to the lab for device fabrication. On May 30th the patient called to tell me that she was, as of June 1st, switching over to a Medicare HMO. I am not a participating physician in that HMO and the HMO does not have out-of-network benefits for office-based physicians. I immediately called the lab to cancel the CROW, but was informed they had started working on it.

The question is, how do I handle this situation? I figure that I cannot bill Palmetto GBA, the regular DMEPOS carrier for the CROW, nor can I bill the Medicare HMO since I don't participate, and they did not authorize payment. The patient stated that she will not pay for the device since she thinks she has coverage. The lab wants to bill me for the item. What’s a doc to do?

Paul Kinberg, DPM, Dallas, TX

Response: With the thousands of regulations Medicare has, you would think there would be one to cover this scenario....well, there, in fact, is. This would fall under the Medicare regulation which covers custom orders cancelled by the patient. In this case, that regulation would permit billing Medicare for a custom item that was, in fact, cancelled by the patient. According to this regulation, the date of service is the date you learned of the cancellation. In your post, that would be May 30. If the lab had not finished making the device, they might also
not choose to charge their usual fee.

You should submit this claim to Medicare with a narrative of what had transpired, and why the order was cancelled, along with a lab invoice. It has been my experience that Medicare will pay your full fee. The rationale for submitting all this documentation at the time of initial claim submission is to avoid having any problems regarding post-payment audits. Should Medicare contact the beneficiary to inquire about whether they received the device, or asked you for a delivery confirmation, you would have to refund monies while then fighting for re-payment.

Another option is for you to contact your orthotic and prosthetic (O&P) ombudsmen, and ask them what to do. It would seem to be reasonable that Medicare allow you to dispense the device after May 31, but bill for it prior to her cut off from Medicare. In this way the patient would receive something, Medicare would actually be paying for a medically necessary item, rather than billing for a cancelled order and the tax payers paying for the delivery of nothing. But because it makes more sense, don't count on Medicare agreeing.

In the future, inform your patient of your office's policies regarding payment, and ask him/her at the time of casting whether they anticipate any changes to their insurance (i.e., going from fee-for-service Medicare to HMO Medicare) prior to delivery of a DME device. Patients *should* know about anticipated changes two weeks prior to their implementation.

Paul Kesselman, DPM, Woodside, NY

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RE Going Bare (Name Withheld )
From: Multiple Respondents

The Learned Editor's cogent and erudite response to this inquiry did not include what I personally consider to be the most important reason for having malpractice insurance: It pays for the cost of your defense when you get sued.

Defending a malpractice action properly can frequently cost my clients well in excess of $70,000. That sum is the average for cases where the fees are computed using the drastically reduced rate I charge insurance companies. It is likely to be significantly higher for "walk-in" clients who get charged the going rate.

In most states, the attorney’ fees you will spend to "protect" your assets, together with what it would cost you to defend a single case, will easily cover your malpractice premiums for a number of years.

Further, the notion that you can truly protect your assets from seizure to pay a malpractice judgment is simply wrong. A determined judgment creditor can make your life a living hell no matter how carefully you may have tried to craft your asset protection.

Purchasing an insurance policy from a reputable carrier not only insures that any judgment against you will get paid, it also insures that you will have knowledgeable, experienced counsel who are ready, willing and able to do whatever you need to have done to defend your honor and your fortune and that they will do it at no cost to you. In my humble opinion, that's a compelling reason to purchase a policy.

Richard W. Boone, Sr., Health Care Attorney, Fairfax, VA, rwboone@aol.com

I don't recommend "going bare," but I do take exception to Dr. Block's reason # 2. Would I feel bad telling a patient who is suing me, "Didn't you read the sign?" You bet your ass I wouldn't. None of us get up in the morning and say, "I think I'll do some harm today.” But if a patient has a less than perfect outcome, they can hire a sleaze ball and sue! I would love to ask the patient to wear a sign when they come in to the office that says, "You better be perfect, I'm the suing type"

Peter Smith, DPM, Stony Brook, NY, ps84@bc.edu

In New Jersey a podiatrist cannot practice without malpractice, it is the law. It is asked on your license renewal form the name of your carrier and amounts.

J Ricketti, DPM Hamilton Sq, NJ, drj4foot2002@netscape.net

I completely agree with the editor. Going bare is "symptom" rather than a method. Presumably your office waiting room sign will "tell" patients you are not insured; and you feel that this will "discourage" frivolous complaints. Unfortunately, if have a seriously compromised result, your patient will complain anyway. Even though you have no insurance, they will contact an attorney anyway.

Attorneys who deal with "bare" doctors have ways to locate assets. In most states it is illegal to "pre-emptively shield" assets against judgments. A lien will probably be placed on them and/or they will be sold to satisfy your debt. There are private investigators who specialize in finding hidden assets. They usually work for divorce attorneys, but they will also work for your plaintiff's attorney.

"Going bare" is a symptom. In a single practice management seminar, you might locate several treatment patterns and codes that will more than pay for the costs of your insurance. This has happened to me after every PM seminar I attended. In my experience, those who do poorly in podiatry suffer from the "virus" of almost every patient being RFC. "Somehow" there are podiatrists who do well. They are doing things that you are not. Rather than going bare, it makes more sense to find out what they do.

Michael M. Rosenblatt, DPM, San Jose, CA, Rosey1@prodigy.net

RE: Barefoot and Magnetism (Mel Cheskin, MBS., C.Ped.)
From: Robert Scott Steinberg, DPM, Bret M. Ribotsky, DPM

And I quote, “By naturally grounding the body electrically (through ESD) and inducing the earth's magnetic field into the body through the feet, we are both reducing our electrical potential to zero (which is optimal) and reinforcing the body's magnetism by contact with the Schumann resonance on the surface of the earth. This is a feature yet to be introduced into synthetic insulated footwear."

Oh really? Please provide us with any legitimate scientific studies supporting your contentions. How about just running barefoot under some high-voltage electrical wires? Mr. Cheskin, give me a break. This type of Vodoo did make me laugh, though. Barefoot running? How many of you have ever treated cutaneous larva migrans?

Robert Scott Steinberg, DPM, Hoffman Estates, IL, Doc@FootSportsDoc.com

Come on, bioelectromagnetism. This is not a science but a theory, never proven. Magnets in shoes don't work either. People are gullible, they buy pet rocks and think there health insurance company cares about them. At a time when we all walked barefoot, we were dead at 40. Society has progressed, we can't change it. Since we both live in Boca Raton, I will share just the past few weeks of new patient visit from kids out of school. A 9 year old boy with large deep laceration from tripping over a sprinkler head running barefoot, a 13 year old girl with 2nd degree burns from walking on hot sand barefoot. A 7 year old girl with a brown reclusive spider bite, again no shoes.

The cost of modernization is shoes. While outside feet need to be protected. In the home, my shoes are the first thing I take off.

Bret M. Ribotsky, DPM, Boca Raton, FL, Ribotsky@doctorbret.com

EQUIPMENT FOR SALE - ESWT

If you are using or thinking of using ESWT, I have a new machine that has only been used twice. There is no Orbasone in the country priced like this one. Will provide training and installation. Take a look at http://www.orbasone.com Call 1-856-229-2939.

PM&S-36 POSITION – SAN ANTONIO, TEXAS

The University of Texas Health Science Center at San Antonio. Contact Program Director, Javier La Fontaine, DPM at (210) 567-5174 or e-mail casteele@uthscsa.edu

ASSOCIATE POSITION - PHILADELPHIA, PA

Full time associate to join large 6-doctor group. PSR-24 trained with excellent people skills. Competitive salary/benefits package. Fax CV and introduction (215) 742-3902.

RESIDENCY POSITION – NORTHERN VIRGINIA

One Year Foot and Ankle/Rearfoot Surgical Fellowship with excellent salary/benefits available July 1, 2006. If you are finishing a PSR24 and don't have a job yet, this is an excellent way to learn additional surgical and business skills. Please fax resume to 703-491-9994.

RESIDENCY POSITION - HOUSTON, TX

RPR, PSR-24, Houston Podiatric Foundation, Starting ASAP. Must have successfully completed PARTS 1 & 2 of National Boards. Contact: Dr. Randal M. Lepow, Director (281-348-3338) (713-725-8988)

Busy, well-established, full-scope podiatry practice, seeking highly motivated podiatrist for a full-time position with buy-in opportunity. Looking for PSR 24/36 trained individual, to help increase surgical volume. Excellent opportunity for long-term growth with unlimited income potential. E-mail CV to employment@associatedpodiatrists.com or fax to (612) 866-5875 Attn. Jennifer.

ASSOCIATE POSITION- NEW ENGLAND

Terrific Opportunity Now Available in growing New England practice. Well established and respected practice with new, large office space, latest technology, very helpful staff, loyal patients and solid referral base. Close proximity to hospitals with modern surgical suites. Opportunity for shared ownership. Prefer 24 month PSR with clinical practice experience or an experienced doctor looking to improve their situation. E-mail CV and particulars to NEAFC3@aol.com

ASSOCIATE POSITION - PALM BEACH COUNTY, FLORIDA

Excellent for upcoming residency grad. Well rounded practice- 2 podiatrists. Fax resume: 561-637-9596.

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