The Voice of Podiatrists

Serving Over 9,500 Podiatrists Daily

July 05, 2007 #2,978 Editor-Barry Block, DPM, JD

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Flip-Flops Not for Everyday Use: TX Podiatrist

It sounds like one of those middle-aged problems, but these days, Dallas sports podiatrist Marybeth Crane is seeing "whole soccer teams of 16-year-old girls" complaining of the sort of foot pain she used to see mostly in "older, fatter" people.

Dr. Marybeth Crane

The culprits aren't the girls' soccer cleats or even the high heels they break out on prom night. Instead, Crane blames their flip-flops - the flimsy, slip-on, toe-thonged sandals that girls and young women nationwide have adopted as their warm-weather, everyday shoe uniform.

"Flip-flops were never meant to be everyday shoes," says Crane, a spokeswoman for the American College of Foot and Ankle Surgeons (www.FootPhysicians.com). "They were meant to wear from the locker room to the pool and back."

USA Today [7/2/07]

CMS Scheduled to Publish 10% Cut in Physician’s Fees

Medicare payments to physicians in 2008 would drop nearly 10% under a proposed rule issued today by the CMS, which projects it will pay $58.9 billion to 900,000 physicians and other healthcare professionals next year. Physician groups have pleaded with Congress to replace the sustainable growth rate formula, or SGR, which is tied to the health of the economy and is used to calculate physician payments under the Medicare program. It has been estimated that payments will drop by more than 40% by 2015 if the SGR is not replaced. Congress in the past has adopted interim measures to stop previous payment reductions.

Efforts have been brewing on Capitol Hill in the meantime to revamp the SGR. In a meeting last week, staff for the House Ways and Means and the Energy and Commerce committees shared with physician organizations a draft proposal to halt the 10% cut from taking effect next year. The proposal would replace the cut with at least a 0.5% increase in 2008 and 2009, and would repeal and replace the SGR payment system.

The CMS’ proposed rule on the 2008 physician fee schedule is expected to be published in the Federal Register on July 12. Comments on the proposal will be accepted until Aug. 31.

Source: Jennifer Lubell , Modern Healthcare [7/2/07]

E-Prescription Faxes May Be Eliminated

The CMS has issued a proposed rule to force physicians and other providers to implement more advanced data transmission standards when sending electronic prescriptions. The proposed rule would eliminate an exception to the technology rules HHS Secretary Mike Leavitt approved for e-prescribing in 2005 that allowed provider e-prescribing systems to transmit computer-generated faxes to pharmacies and pharmacy benefit management, or PBM, companies. In November 2005, HHS published a final rule adopting e-prescribing standards as authorized under the Medicare Prescription Drug, Improvement and Modernization Act of 2003. The rule is to be used by physicians and suppliers under Medicare Part D.

The proposed new rule, included as part of the physician fee schedule for 2008, would require all e-prescribing transactions between providers and pharmacies to be in the Script standard developed by the National Council for Prescription Drug Programs, a not-for-profit, American National Standard Institute-accredited standards development organization.

In a two-page "fact sheet" explaining the proposal, the CMS said that leeway was granted in 2005 because, "absent this exemption, entities using e-prescribing software that generated faxes would either have been required to comply with the Script standard or revert to paper prescribing. CMS expected that entities using computer-generated fax software would adopt the use of the Script standard over time, but this has not occurred to date." A public comment period on the proposed rule is now open and will be accepted until Aug. 31.

Source: Joseph Conn, Modern Healthcare [7/2/07]

Query: Refund of Overpayments

During the past 2 months, United Healthcare has started taking back "overpayments" from 3 years ago on several different patients. But instead of requesting a refund, UHC is taking back their payments through the reimbursements to be paid for other [non-related] patients. For example, they say they overpaid us on "Patient A" 3 years ago, and now they want their refund, so they are taking it out of "Patient B's" reimbursement.

It seems totally unfair in that it assumes I was wrong in how was paid originally...and I am not given due process to appeal their actions since they have taken the money they think is due them. Can they just do this? Isn't there a time frame (certainly less than 3 years!) limiting when they can take back an overpayment they are claiming to have? This has never happened to me before. What can I do?

Bernard Vierra, DPM, Lafayette, LA

Response: Can payers do this? Probably yes, if not precluded by state law or your provider agreement. How far back can they go? To the beginning of your contract unless limited by state law or your provider agreement. Are you entitled to "due process?" Again, what do your state law and the terms of your provider agreement say on this issue?

Get the picture? If you were not proactive at the time the contract was signed, and especially if your state law does not offer physician-friendly protections against this disingenuous payor tactic, you may be out of luck. Solutions? Well start by reading these two articles on my website. They'll give you lots of food for thought. Share them with your practice attorney and see if Louisiana law offers you any protections. (Note: do not worry that the second article was written for ophthalmologists. All of the issues discussed there apply across medical specialties.)

Podiatry Management, August 2006
http://gilweber.com/gw_pro57.htm

Ophthalmology Management, March 2002
http://gilweber.com/gw_pro32.htm

If you're lucky Louisiana law will offer you a means to tell UHC to go pound sand. In any case, use this information as the basis of renegotiating your UHC provider agreement (amending it) and for negotiations in all future contracting. And if UHC or any other payer says, "No," to the issues I raise in the two articles then they're showing you a big red flag and saying "We reserve the right to mess with your reimbursements, even if we were the ones who created the problem by giving you an incorrect authorization or eligibility verification. Too bad." And if that's the case it's time to walk away from that contract!

Gil Weber, MBA, Viera, FL

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RE: Value of Deceased Podiatrist’s Charts (Catherine Wu, DPM)
From: Richard W. Boone, Sr

The short answer is "nothing." This does not mean that there is no value for an ongoing practice. But this practice is clearly not "ongoing," given the death of the proprietor. It merely means that the value of any practice is inclusive of a great deal more than just the patient list or old charts. Unless you get those other things, which are mostly intangibles, the patient lists and charts are of no particular value.

Someone, probably Dr. Wu, needs to alert the estate of the deceased practitioner to the fact that the practitioner's obligations with regard to patient records DO NOT end with the death of the doctor. The deceased physician's estate has the same obligations to former patients with regard to their records as the practitioner would have if he or she were still alive. In my state, for instance, that means that the records have to be maintained, and be accessible to former patients, for a period of time. In my state, in most instances, that means for six years. Maintaining those old records for such a period is obviously a problem for the estate. And it will cost money which the estate doesn't want to spend.

So what I would recommend to Dr. Wu is that she offer to take possession of the deceased physician's records and maintain them as a service to the estate of the deceased physician. Once she has possession she can, and probably should, send notices to former patients advising them that she now has their old charts. (In my state she would actually be legally obligated to do so.)

This benefits the estate, because it relieves it of the burden of maintaining the records. That is the estate's "payment" for the charts and patient lists. On the other hand, the cost to Dr. Wu is relatively small, since adding these old charts to her existing records system should be relatively inexpensive and the publicity involved in the notice to former patients should generate additional income sufficient to offset that expense. That's her "payment" for agreeing to accept and maintain the records. This kind of arrangement, therefore, should be beneficial to all concerned. More importantly, it facilitates the continuity of care for the patients of the deceased physician which should be the goal of the entire exercise.

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

RE: Using a Higher Concentration of Alcohol For Neuromas (Amy Schunemeyer-Purdy, DPM)
From: Michael M. Rosenblatt, DPM, Paul Kesselman, DPM

Physicians who prefer to use a larger dose than the "typical" 4-6% ETOH may be using this concentration for other anatomical areas other than the human foot. Since we are podiatrists, we must keep our discussion to the foot and ankle.

There is a "limited tissue base" surrounding the nerves that most regard as a target for neuroma pain. Insurers might also complain about some podiatrists using ultrasound targeting for such injections. The issue of post-procedure pain cannot be neglected in this discussion. It is reasonable to assume that more pain will occur after a higher concentration is used because of that "limited tissue" substrate, and the inevitable fact that some alcohol will also contact those sensitive surrounding tissues.

Insurers seem to believe that podiatric treatment is "less important" or "complex" than other anatomical areas; especially comparing our own specialty to other doctors. The automatic assumption by them is that "podiatrists should charge less" because they are podiatrists, and that the foot is less important anyway. Not so. The element of "surrounding tissue exposure" must be a part of this discussion. That has nothing to do with fees, in of itself.

Michael M. Rosenblatt, DPM, San Jose, CA, ROSEY1@prodigy.net

It is truly amazing at the firestorm that my recent posting regarding the European study on alcohol injections created. Having read the study, courtesy of a fellow radiologist, it dwarfs any previous studies performed in the podiatric literature. Much work however is left to be done before drawing definite conclusions (other than 4% is inadequate).As per the European study, failed conservative therapies (e.g., padding and strapping, orthotics, steroid injections) should be attempted prior to the use of alcohol injections.

I'm left wondering: Is anyone conducting RCT with double-blind studies? If so, what concentrations are being used? What types of sonography equipment is being used, and how well trained are the users in sono? Are the examiners all radiologists and if not, what other specialists are involved? What are the economic reimbursement comparisons of surgery (open or endoscopic) vs. multiple alcohol injections vs. radio or cryoablation?

Paul Kesselman, DPM, Woodside, NY, pkesselman@pol.net

RE: AAOS and Podiatry (Bryan C. Markinson, DPM)
From: Barry Mullen, DPM , Howard Lazar, DPM

I vote to simply refuse to exhaust any further negative energy getting into mudslinging contests with orthopedists. Let's simply demonstrate to the rest of the medical community our true class by taking the high road, for two wrongs don't make a right. Shutting out those true healthcare professionals who respect our profession and wish to learn from and with us is a huge mistake, just as AAOS' decision is. Rather than badmouthing those orthopedists who purport themselves to be expert foot surgeons who lack the necessary training, instead, let's focus positive energy into continuing to promote podiatry to the public, PCP's and other referral sources as THE foot surgery experts. Assuming orthopedists are your enemies is a huge mistake. We need to recognize, respect and embrace those orthopedic foot and ankle surgeons who have advanced their basic orthopedic training regardless of whether the good will is shared or not. How else can one form a professional bond?

While it would be ideal to be "accepted" by AAOS to establish working and teaching relationships, thereby fostering an atmosphere that benefits foot and ankle healthcare delivery, not only is this not vital to our existence, their podiatric excommunication is a huge mistake in judgment and their loss. Besides losing potential referral sources, with specific respect to the future performance of quality foot surgery, without podiatry leading the way, who's gonna teach them right from wrong...other orthopedists who very possibly might lack the necessary training.

Barry Mullen, DPM, Hackettstown, NJ, YAZY630@aol.com

It is apparent that AAOS' attitude toward podiatry is not based on any concerns for the quality of care. They are waging a turf war, fueled by egos and dollars.

Surely, I cannot be the only podiatrist who recognizes that the ABPS, similarly motivated, behaves in exactly the same way toward the rest of the podiatric profession. The only difference is that the ABPS is trying to achieve exclusivity for itself in all podiatric surgery. The ABPS has worked diligently in its attempts to keep non-members out of the operating rooms and managed care plans. Quality of care is not the issue. It is, again, a turf war driven by egos and dollars.

The ABPS is now concerned that its reconstructive rearfoot and ankle certificants will not be allowed to perform ankle surgery, and they expect the rest of us to rally behind them to help secure for them what they deny us. Where is the quid pro quo? I don't see any ABPS members coming to the aid of non-members in securing hospital privileges, or provider appointments in managed care plans.

Howard Lazar, DPM, Bloomfield Hills, MI, howardlazar@comcast.net

PRACTICE FOR SALE -FORT LEE, NEW JERSEY AND MANHATTAN

Nice mix of commercial insurance, Medicare, cash, routine care, surgery. Experience the NY metro life with shopping, dining, professional sports, culture at your doorstep. AMERICAN DOCTOR SALES 614-918-3000 or email us at sell_my_practice@yahoo.com

EQUIPMENT FOR SALE - WASH. DC

Name your reasonable price and pay shipping- Body chairs, X-Cell X-rays, Konica developer, SmartDop20, viewboxes, lakesidecart, Endoscopic unit with all attachments, topical hyperbaric O2 units, castle autoclave, xerox copier, fax machines, etc. call 202-841-5545 or email to JHALLUX@yahoo.com

ASSOCIATE POSITION - MIAMI BEACH, FL

Seeking well trained PMS 36 / PSR 24+ for Full-Time associate position. Leading to partnership for the person. practice is 50% hospital based. Must have strong Sx skills, including Limb Salvage & Trauma. Competitive Salary & benefits Package. Fax 305-652-6672 or Call 305-785-2559 Email: doctorsole@aol.com

PRACTICE FOR SALE - RIVERSIDE, CA

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Practice grossing over 250K/yr three days/wk. room to expand, large physician referral, good mix of sx., wound care, DME's, routine care. no rest homes. Medicare cert. surgery center on site. Will consider associate-to-purchase. may carry paper. Consider all offers. Office and sx. center also for sale. e-mail tentoes001@hotmail.com or call 951 7804782.

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ASSOCIATE POSITION FLORIDA - NORTHEAST REGION

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Busy, well established, full scope podiatry practice seeking highly motivated, hard-working, reliable, responsible and especially likeable to the average human, Associate. Surgical training a plus. Prefer PSR 24+. This is an Associate position with lots of potential. Team players only. Email CV to: healthparkmgr@bellsouth.net or fax CV to: 904-826-1586, Attn: Amy

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POSITION AVAILABLE - SOUTHEAST TENNESSEE/ NORTH GEORGIA

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Immediate position available or will wait for the right individual. Unique practice opportunity in growing multi-physician/multi-office practice. Well established/cutting edge within the medical community. Close proximity to hospitals as well as opportunity to become involved with a free standing podiatric surgical center. Must be BQ/BC. Minimum PSR/24. Competitive salary, bonus structure and benefits. E-mail CV to afcjen@hotmail.com

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