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RE: Autofax Pharmacy Refills

From: Keith L. Gurnick, DPM


My office often receives far too many faxes from pharmacies asking me to authorize prescription refills for my patients. This past year, before authorizing or declining the refill, I called or sent an e-mail to each patient, asking them if they wanted or needed the refill and if they had requested the refill. To my surprise, almost 100% of the time, the patient said they knew nothing about the fax, and had not initiated any request and they did not need the medication any longer.


My office is inundated with faxes on a daily basis from outsourced carriers asking for medical records, physical therapists who send cut and pasted medical records asking for my signature and a return fax to authorize continued care, and these unwanted faxes from pharmacies for prescription medication refills that were never requested by anyone. My office has to send back a reply fax to the pharmacy denying the request for the refill, or they will continue to send the faxes many times.


Any suggestions on how to curtail these endless unwanted faxes would be appreciated. I am aware that I could get rid of my fax machine but I also receive faxes (MRI reports, etc.) that are important such as insurance credit card payment vouchers and others. Can't something be done on a legislative level to stop the pharmacies from auto-faxing prescription refills when no one ever asked for the refill?


Keith L. Gurnick, DPM, Los Angeles, CA

Other messages in this thread:



RE: Donations to Our Volunteer Clinics

From: Drs. Maria Buitrago, Richard Rees, Eugenio Rivera, Andrew Schneider, and David Wolf


We would like to thank Marlinz Pharma for their generous donations to help with our volunteer podiatry clinics at San Jose, St. Mary’s and Healthcare for the Homeless programs. These programs benefit the less fortunate people in our Houston communities by helping patients who are not able to otherwise seek treatment for their foot care issues.  


Kudos to Megan and Perry with Marlinz Pharma who have generously donated these products (as well as paid for shipping) which demonstrates true generosity without seeking any recognition. 


Drs. Maria Buitrago, Richard Rees, Eugenio Rivera, Andrew Schneider, and David Wolf



RE: Educate Patients About Insurance Companies  

From: Peter J. Bregman, DPM


People need to be educated on what insurance companies really are. They are money exchangers or money transferring entities. They transfer money from their subscribers or customers, keep a large chunk of it, and give a small percentage to the actual health caregivers. It is funny that when you ask patients what is the purpose of health insurance, most of them say, "I have no idea; they just take my money." 


It would be great if we could post how much money all of the CEOs and CFOs and COOs make and put it into commercials, and juxtapose that with all the times they deny patients any type of care, or show how much they pay for a three-hour surgery, etc. People need to wake up.


Peter J. Bregman, DPM, Las Vegas, NV



RE: Malpractice and Billing

From: W. David Herbert, DPM, JD


When I was a malpractice attorney, the first thing I would look at was the billing records. If the billing records raised some red flags, I found in most cases that the medical care was also at least questionable. Of course, that was years ago. I guess it is still applicable not only for podiatry but for other specialties also.


W. David Herbert, DPM, JD, Billings, MT



From: Leonard A. Levy, DPM, MPH


Bart Holt, DPM queries, “Why Don't Dentists Become MDs and Why Don't MD Specialists Practice Primary Care?” (PM News April 11, 2022). During my tenure as Associate Dean for Research and Innovation at the College of Osteopathic Medicine of Nova Southeastern University, I worked with the dean of the college (the late Lawrence Jacobson, DO) and the chair of the Department of Oral Surgery in the School of the College of Dental Medicine (Steven I. Kaltman DMD, MD, FACS, now dean of the College of Dental Medicine) to develop a program for dentists who also wanted to obtain a DO degree.


In 1940, the Harvard School of Dental Medicine (HSDM), to place stronger emphasis on the biological basis of oral medicine and to institute...


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



From: Name Withheld


There are two current CPT codes for arthroereisis. CPT code S2117-arthroereisis, subtalar, which is considered a surgical services temporary national code. There is also CPT code 0335T—insertion of sinus tarsi implant. It has been suggested by some that providers use an unlisted code, which in my opinion is incorrect. As per NCCI policy, a procedure must be billed to the highest specificity. And an unlisted code should also only be used when there is NO code to describe the service. In this case, there is a CPT code.


Many have tried to dance around this issue by billing as a subtalar arthrodesis or ORIF of a talo-tarsal dislocation. This is 100% insurance fraud, whether someone has “gotten away with it” or not. I assure you it would...


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



From: Connie Lee Bills, DPM


I am very happy with Ovation Medical. I’m not sure if they have pediatric sizes, but the boots are great. 


Connie Lee Bills, DPM, Mount Pleasant, MI



From: Elliot Udell, DPM


Thank you Dr. Moglia for bringing our attention to a potentially new drug that can help us in the treatment of recalcitrant viral warts. The mechanism of action of this drug is to cause a hypersensitivity or an allergic reaction which can cause verrucae to abate. This is not the first time that we have used a drug that causes hypersensitivity to treat warts. Injections of Candida is one example, the topical use of cantharone is another. The problem with all of us jumping on the wagon and using diphencyprone is that the literature also reports a fair number of potential side-effects such as severe eczema which can become systemic and even one case of anaphylaxis.


Because the amount of patients studied is still very small, it is hard to tell whether these side-effects are common or extremely rare; do we need special training to handle them. Perhaps before using this particular drug, we should not be "the first kid on the block" but better wait for more clinical studies to make sure it is completely safe for use in private practice settings. 


Elliot Udell, DPM, Hicksville, NY



From: Dieter Fellner, DPM


Dr. Caringi correctly asks "how do you explain excellent durability without addressing the frontal plane?" Conversely, we may ask how we can explain the many failures, also. The answer is paradoxically quite simple, but in a very complex way: not all first metatarsals demonstrate significant pathological changes in the frontal plane alignment. This is likely a continuum presentation.


A first metatarsal may be plantar-flexed (mobile, semi-rigid, or rigid). There may be significant metatarsus primus adductus. A hallux abductus may dominate the bunion foot. Often there is a combination of both. Weight-bearing influence will largely affect...


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



From: Dennis Shavelson, DPM, CPed


I was waiting for some innovative DPM to come up with new terminology that would completely eliminate "Biomechanics" from the podiatry dictionary. Here is the first: Durability.


What we actually need is new terminology for "subtalar joint neutral" and "pronation" (as other professions are accomplishing) in order to evolve biomechanics parallel to how we have evolved foot surgery, wound care, and regenerative medicine.


Dennis Shavelson, DPM, CPed, Tampa, FL



From: Greg Caringi, DPM


With reference to bunion surgery, my old professor Dr. James Ganley used to query, "how many bad results can you afford to be limping about your town?" Frontal plane correction can be obtained with any planar osteotomy (e.g. Homann, Wilson). Predictors of recurrence have been shown to include post-operative sessions positioning, residual hallux valgus, residual IM angle. A multitude of other factors such as degree of pronation, metatarsus adduced, ligamentous laxity are obviously significant. However, there is a clear difference between recurrent or residual hallux valgus and patient satisfaction. Distal metaphyseal osteotomies and diaphyseal osteotomies have very high patient satisfaction rates even with some degree of residual or recurrent deformity. 


There is a difference between the theoretical and the practical. If procedures such as the Austin-type bunionectomy are "doomed to failure", why is this the most commonly performed bunionectomy? Are we all stupid, non-observant, or uncaring? Or is this yet one more example of corporations and their spokespeople attempting to define the standard of care. Furthermore, we see trending MIS surgical bunion correction. How do we reconcile this reversal of the Lapidus philosophically? Again, as Dr. Ganley told us, “beware of the technological imperative!”


Allen Jacobs, DPM, St. Louis, MO



RE: Indicators for Durability of Bunion Corrections

From: Greg Caringi, DPM


Current SOTA bunion surgery aims for triplanar correction of the 1st metatarsal segment. The missing link for many years was lack of frontal plane correction because there were few procedures (old school DRATO; new school CoLink Vallux) that allowed a surgeon to address this obvious compensatory deformity with a distal osteotomy. The modern Lapidus procedure gets the job done but I often question the use of this somewhat complex procedure in mild-moderate deformities.


When I trained residents years ago, I always taught that reduction of the sesamoid position was the key indicator for surgical durability. I still believe this to be true even with uni- or bi-planar corrections (as in the many variations of the Austin procedure). I did not know about the "round sign" back then. Although Lapidus loyalists argue that this can't be true, I am here 40 years later to tell you that I have seen happy patients 10, 20, and 30 years following their Austin bunionectomies (with no frontal plane correction) with no recurrences.


I am in favor of advancing our surgical procedures. I am asking what today's foot surgeons are using as their primary indicators for durability of bunionectomies - IM angle reduction, sesamoid position, the round sign? And, how do you explain excellent durability without addressing the frontal plane?


Greg Caringi, DPM, Lansdale, PA



From: Leonard Kuzmicki, DPM


We used to use 3-WEA on nails and calluses, but as Dr. Ressler notes, at the recommended dilution it wasn’t really softening enough, and at a more potent dilution, it made the skin slippery and also left a residue on treatment chair surfaces as it dripped off the foot. We had to quit using 3-WEA when it was discontinued years back. I switched the usual 10 blades to 313 chisel blades to trim calluses and never resumed use of 3-WEA when it started production again. The heavier blades don’t flex like the 10s going through thicker calluses and makes it much easier to take them down. The round beaver handles are more comfortable in hand than the scalpel handles too.


I replace my nail nippers more frequently as I found that having them sharpened wasn’t worth the time and expense and didn’t fully restore the fresh edge they had as when new. After eliminating the 3-WEA, I found that I was much happier to do routine foot care, and my work area and treatment chairs stayed much neater. I’ve had maybe a half dozen patients actually say that they missed getting the 3-WEA treatment.


Leonard Kuzmicki, DPM, Spring Valley, IL



RE: Medicare Advantage Plans 

From: Richard B. Feldman, DPM


I would like to share one of my experiences with a Medicare advantage plan. I received a request for a refund from one of these plans. It was a legitimate request, as 2 years ago I used an incorrect code on a hospitalized patient. I contacted my provider representative for this plan. I told her about this request.


I informed her that I would be happy to refund the money, if they would pay me the money for cutting toenails and calluses on the same visit. She asked me to send her examples of these denied claims. I sent her six claims. That was four months ago. I have not heard anything about this refund to date. 


Richard B. Feldman, DPM, West Haven, CT



From: Donald Blum, DPM, JD


If you do not have a source for your old x-ray machine, before putting it in the dumpster:


1) Try Ebay minimal bid $1.00 - describe as "as is" and "must pick up in (city, state)”

2) In Dallas, there is a website "trash nothing"

3) Contact a reseller of used equipment (same as Ebay) “as is” and must pick up


Donald Blum, DPM, JD, Dallas, TX



From: Sev Hrywnak, DPM, MD


Dr. Kornfeld inquired about the use of peptide BPC-157. There will be a seminar for certification for podiatric physicians on the use of peptides this September 10-11, 2022 in Chicago. More information will follow in PM News.


 Sev Hrywnak, DPM, MD, Chicago, IL



From:  Alan Sherman, DPM, John Mozena, DPM


I 100% agree with Dr. Mullens' comments on insulting other podiatrists in PM News and applaud his raising of the issue. We are colleagues of an advancing increasingly appreciated profession and have no time to waste on petty squabbles. By all means, let’s disagree, for that’s how we grow – but let’s be civil, polite, and considerate to each other in this public forum. Let’s respect each other for our respective achievement and hold each other in high esteem. As Bones said in the Star Trek iterations, “God dammit it Jim, I’m a doctor, not a bricklayer.”


Alan Sherman, DPM, Delray Beach, FL


David Mullins is such a bright star for our profession! From his early years as a lecturer to his recent profession of helping all of us with his legal knowledge. His humor and wisdom should be an example for all of us. I hope all of us will remember his thought on the importance of kindness towards each other. Thank you for all you’ve done for podiatry! 


John Mozena, DPM, Portland, OR



From: John M. Giurini, DPM


Thank you, Dr. Mullens. I could not agree with you more. I would go one step further: Stop the insults altogether. Unfortunately, society, from the highest levels of government to social media to town halls and school boards have forgotten how to discuss and debate issues rationally. This type of rhetoric makes no one look good or better, especially the individual handing out the insults. Dr. Mullens got that part right. As a profession, let's raise our standards above the unfortunate "new normal". Let's show other professionals and the public (yes, they read this). that we are able to disagree without being disagreeable.


John M. Giurini, DPM, Boston, MA



From: Donald R Blum, DPM, JD


My dermatologist accepts Medicare assignment but does not accept other insurances. When you accept assignment, it is "ONLY" for services that you know are not excluded from coverage. For services that are excluded, you can accept payment at time of the service. 


If you follow the CMS rules and guidelines strictly, I think you should do okay. All services provided to diabetic patients (whether on Medicare or not) are not necessarily a covered service if the patient does not meet the class findings (Q7, Q8, Q9).


One more item - remember for 2022, there may be a decrease in the Medicare reimbursements (due to fee reductions and sequestrations).


Donald R Blum, DPM, JD, Dallas, TX



From: Ron Freireich, DPM, Burton Katzen, DPM


We had this exact problem here in Ohio and we checked with our patients to see if they initiated the refills. They too did not request the refills.  We filed a complaint with the State of Ohio Pharmacy Board. The faxes quickly stopped.


Ron Freireich, DPM, Cleveland, OH


Unfortunately, with the single sheet faxes of today, even when you mark unsubscribe, they still keep coming and it is hard to stop. Many years ago, I was getting 3-4 faxes a day from one company advertising office furniture. At the time, we had a fax that used a paper roll, and I attached 3 pages together (top of the 1st one to the bottom of the last one) that said UNSUBSCRIBE, called the number and left for the night. Surprise!! No more faxes from them. I always had a vision of them not being able to get in the office the next morning because of the mass of paper blocking the door.


Burton Katzen, DPM, Temple Hills, MD



From: Elliot Udell, DPM


Kudos to Dr. Simmons for bringing up an issue that has long affected and annoyed all of us. When we write a prescription for a topical antifungal, we never know if the patient's insurance company will either allow it, reject it, or hit the patient with a "million dollar" co-payment for it. The latter will generally result in either the patient and/or the pharmacy chasing after us to try to find an alternative antifungal that is covered with a reasonable co-payment. 


Since many topical antifungals are OTC products and many of our podiatry suppliers are happy to stock our shelves with them, dispensing these products is a good option. If the patient must get the medication via his or her pharmacy, one method that has worked well with us is to write for a specific cream and give the pharmacist permission to substitute an alternative topical antifungal that is covered by the patient's insurance company. This avoids calls back and forth from the pharmacy while the pharmacy staff searches for the product that will be covered. 


Elliot Udell, DPM, Hicksville, NY



From: Dieter J Fellner, DPM


Reinforcing the notion of a Cinderella service since time immemorial, the podiatric physician-surgeon is not 'permitted' to administer COVID-19 vaccinations. There is an extensive, and growing, online debate about the fact that those staff, with lesser training and education, yet legally empowered to do so, have no idea about aspiration, prior to injection. 


Increasingly, the intravascular injection is now linked to adverse health sequelae, such as increased coronary syndrome with a spike in myocardial infarctions. This important aspect of injection technique is second nature to all podiatrists. This is a global problem. Our 'leaders' are again failing the nations of the world adding to their catalogue of shame in managing this 'crisis'.


 Dieter J Fellner, DPM, NY, NY



From: Elliot Udell, DPM


This issue has been discussed for quite a few years in this forum. Why is it that pharmacists can administer many vaccinations and podiatrists and dentists who give injections all day long, cannot? During the height of the first wave of the COVID-19 pandemic, some states in the U.S., including my own, issued temporary permission for podiatrists to administer COVID-19 vaccinations but only under the supervision of one of the other professionals.


A number of our colleagues took advantage of this and generously volunteered their time giving shots at mass vaccination centers. The fact that this did not lead to allowing us to give flu and COVID-19 shots permanently, does not do justice to the public, especially in areas where a podiatrist or dentist is the only healthcare professional that some elderly people see.  


Elliot Udell, DPM, Hicksville, NY



RE: No Sane Rationale for Prohibiting DPMs to Vaccinate

From: Name Withheld (TX)


I do not understand the world we live in. In Texas (and perhaps other states), DPMs cannot give flu shots or COVID-19 vaccines. Is this insane? RNs, LVNs, NPs, and mid-levels can give these injections but not podiatric physicians. DPMs are trained in administering injections and dealing with adverse reactions much better than the local pharmacist. The reason given for not allowing DPMs to give these vaccines? Flu and Covid are systemic illnesses. Crazy!


Name Withheld (TX)



From: Burton J Katzen, DPM


After reading Dr. Wallace's "Advice from a Retiring Podiatrist", as another podiatrist contemplating retirement, several things come to mind.. My first thought was of Mickey Mantle, Willie Mays, Sandy Koufax, etc. who were "born too early". I believe Dr. Wallace would have been happier in our wonderful profession practicing as a chiropodist in the 1st half of the 20th century. It's hard to imagine practicing the same way and with the same techniques as when I graduated in 1971 and not trying to learn new innovations and techniques.


I can't help but feel sorry for him that his way of practicing has robbed him of the utter joy of permanently correcting thousands of painful deformities of his patients and the joy of trying new innovations that might have greatly improved his patients’ outcome and lifestyle. However, if that worked for Dr. Wallace, neither I nor anyone else should judge the way he practiced.


I find it hard to believe that Dr. Wallace's other such positive lifestyle choices, which I mostly agree with, are in such conflict with the advice he has given; with the possibility of permanently changing lives and allowing his patients to partake in the same joys of life, one such joy being long non-painful walks by providing the latest treatment options available, basically advising us to stay status quo as a profession. Anyway, if another close-to-retiring podiatrist might give advice, do whatever it takes to achieve the practice and life goals you have set for yourself, keep learning, and advancing your skills, give your patients the best and latest treatments available, and don't listen to anyone else's advice on how you should live your life or practice your profession.


Burton J Katzen, DPM, Temple Hills, MD



From: Stephen Musser, DPM, Ivar E. Roth DPM, MPH


Well done and written. I agree with every point you mentioned. For those of our colleagues who have been practicing less than 8 years, you will come to find this advice is well thought out and true.


Stephen Musser, DPM, Cleveland, OH


Congrats on your retirement George. Thanks for your advice. I would add though, that if you are conservative and do NOT sell surgery, you should inform patients and let them make the decision to have surgery or not; you will save yourself a lot of headaches. You will do less surgery, but since the patient made the decision, you will be safe from criticism.


Ivar E. Roth DPM, MPH, Newport Beach, CA 

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