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04/11/2022
RESPONSES/COMMENTS (MEDICAL-LEGAL) - PART 1B
From: Elliot Udell, DPM
When I was doing surgical procedures that required the prescription of controlled substances, there was a need for a DEA number. At this point in my practice, I did not see the necessity to pay over 1,000 dollars to renew my DEA, so I let it go. All of the insurance companies are fine with it and will use my NPI number. Some will ask if you have a primary care doctor to write for controlled substances, when and if you need them. That was no problem either.
The only little problem is that one drug company that I occasionally did business with will not sell, even lidocaine or bandages, to any doctor who does not have a DEA number. I wonder if they are legally allowed to discriminate against doctors who do not wish to prescribe controlled substances.
Elliot Udell, DPM, Hicksville, NY
Other messages in this thread:
05/13/2023
RESPONSES/COMMENTS (MEDICAL-LEGAL) - PART 1B
From: Robert Kornfeld, DPM
You see what lurks in the fine print of your contracts? My advice is to go to a direct-pay practice with a strong niche. This insanity has to stop!
Robert Kornfeld, DPM, NY, NY
05/04/2023
RESPONSES/COMMENTS (MEDICAL-LEGAL) - PART 1B
From: Steve Abraham, DPM
Ciox requests can take 10 minutes to respond to. Ciox presents a portal to upload chart notes. Your EHR should be able to save a chart note in PDF format. Make a folder on your desktop, and save all the .pdfs to the folder. Log onto the portal and upload all. It is a very quick and efficient way.
After you are done, delete the folder from your desktop to comply with HIPAA rules.
Steve Abraham, DPM, NY, NY
01/16/2023
RESPONSES/COMMENTS (MEDICAL-LEGAL) - PART 1B
From: Kristin Happel
The amount of "risk adjustment" chart requests is always commensurate with how many patients you have seen in the previous year with those particular MA plans. You see 50 patients with that MA plan, you get 50 chart requests. At least that has always been my experience. I went from charging $25 a chart in previous years to $50 a chart for 2021 charts. In 2023, I will up that to $75 a chart for 2022 charts.
CIOX or whoever is requesting the charts always pays what I invoice them for BEFORE I send the records. And yes, I have reviewed my insurance contracts to make sure this is legal. Bottom line is this: these MA plans are trying to get more money from Medicare, by doing these "risk adjustment" chart reviews. While I guess that is their prerogative, it is MY prerogative to make them pay for that "info". I can only hope at some point they realize they are paying more out for their "precious info" then they are taking in for it.
Kristin Happel, Podiatry Biller, Chicago, IL
12/07/2022
RESPONSES/COMMENTS (MEDICAL-LEGAL) - PART 1B
From: Paul Kesselman, DPM
Several years ago, I was confronted with a steep hike in DEA registration fees and my discontinuation of full-time practice and going non-surgical. At first, I received many calls from insurance companies insisting that I must have a DEA number or provide some alternative to providing narcotic prescriptions to my patients. At the advice of others, I relented and paid the fee, simply to get the insurance companies off my back. Three years later, when another steep hike was instituted, I had enough. I informed the insurance companies I would refer the patients either to another podiatrist in the area who saw patients requiring narcotics and who was willing to do so, or I would refer them to the ER for podiatric care. The letters stopped and the requests for providing a DEA number, even from CAQH, stopped.
Before I took this step, I called my state board of pharmacy to be sure that no DEA number was required in NYS to prescribe non-narcotic medications. What I was told was that there was a short list of non-opioids, including Tramadol and Lyrica, which did require a DEA registration, but for the most part, non-narcotic medication prescriptions do not require the practitioner to be registered with the DEA. I also called my pharmaceutical suppliers who told me the same thing.
My suggestion is for you to check with the NJ State Board of Pharmacy and also check with a few of the top insurance carriers you participate with prior to making any decisions, and proceed accordingly.
Paul Kesselman, DPM, Oceanside, NY
06/01/2022
RESPONSES/COMMENTS (MEDICAL-LEGAL) - PART 1B
From: Clifford Wolf, DPM
State license laws that address best practices for prescribing medicine to treat gout fall into grey areas. Some doctors are comfortable and confident to therapeutically treat, others are not. For both groups, do you possess mastery of nephrophysiology and internal medicine to defend efficacy of your treatment? If you do, please help your patient.
Clifford Wolf, DPM, Oceanside, CA
05/31/2022
RESPONSES/COMMENTS (MEDICAL-LEGAL) - PART 1B
From: Joe Agostinelli, DPM
I think that we all should be able to diagnose and treat a foot/ankle suspected or known acute gout attack to a joint. For example, aspiration of the great toe joint, synovial fluid crystal analysis to establish actual gout is a common occurrence in clinical practice. As we well know, the fluid aspirated is very often actually seen as gout with tophi. Then, injection of local anesthesia/steroid injection into the joint is appropriate. Rx for indocin, 5 day course, or Medrol dose pack, if recurrent attack, is also appropriate and in the realm of our practice, as short-term acute management.
Laboratory orders for uric acid blood level and referral to PCM is also a prudent plan after your initial gout attack diagnosis and in-office treatment. I agree with Dr. Jacobs and those who do not recommend continued medical management of "hyperuricemia". In my clinical experiences in a multi-disciplinary hospital-based, clinical USAF practice, and then in an orthopedic surgery group practice. This approach has been accepted well by PCMs, rheumatologists, nephrologists, internal medicine docs to whom the patient is referred. I can assure you that those specialists are very happy to have a joint aspirate confirming gout rather than just elevated uric acid levels. We all are aware of patients who say, "I have gout," but there is never a definitive joint aspirate confirming that diagnosis!
Joe Agostinelli, DPM (Retired), Niceville, FL
05/26/2022
RESPONSES/COMMENTS (MEDICAL-LEGAL) - PART 1B
From: Charles Morelli, DPM
I agree with Dr. Girling that “Our job is clear, our license is not” and I do whatever it is I can, within the scope of my license and my education, but there are times when other PCPs and rheumatologists do not treat a patient properly or aggressively enough to take care of their initial symptoms. I just had a patient this morning that came in and told me that their doctor told them that they have gout and s/he gave them 100mg of allopurinol. No blood test, no x-ray, no previous history; just that their toe was painful, and this happens all of the time. This patient needed colchicine and steroids initially.
As an aside, I have also had many patients over the years who were told that they have psoriatic arthritis. No skin lesions, no nail changes, no negative RF or x-rays changes (joint swelling, dactylyitis), and no family history of psoriasis. Yet they are told they have...
Editor's note: Dr. Morelli's extended-length letter can be read here.
05/25/2022
RESPONSES/COMMENTS (MEDICAL-LEGAL) - PART 1B
From: Lance Malusky, DPM
I also would treat gout as needed. Upon initial presentation, we would take appropriate x-rays, prescribe a generic NSAID, and send the patient for stat lab work-ups. With a positive history of gout, or an obvious clinical presentation, I would immediately prescribe colchicine with the usual caveats, and allopurinol. Repeat labs would be done once the attack had subsided, and the patient would be referred to the PCP, with paper copies of the labs for consideration of future management.
If the PCP was not sympathetic with treating a future acute attack, I would provide an Rx of colchicine for the patient to fill as needed, with the caveat that they were to return ASAP for a new assessment. Often, these patients preferred my care for the next attack. A few would also prefer my practice for permanent follow-up. In that case, periodic labs every 3 months are indicated, if maintenance with allopurinol or Uloric is necessary. I never had a family doctor complain that I overstepped my license.
Lance Malusky, DPM, Kettering, OH
09/22/2021
RESPONSES/COMMENTS (MEDICAL-LEGAL) - PART 1B
From: Philip J. Shapiro, DPM, Jack Ressler, DPM
The issues always come down to motive and opportunity, and the need for a secure system to prevent employee theft of financial assets. Under the circumstances, it would be advisable to contact an attorney who specializes in employment law for guidance as to how you should respond.
Philip J. Shapiro, DPM, Ormond Beach, FL
Yes, the employee should be confronted and fired. $25 to $50 (a week) is not a great deal of money but you have a dishonest employee in your office working in a position that could cost you thousands even with a balanced bank statement. An employee like that could do many things that would cost you money. From not filling an open appointment slot to laziness in insurance billing, your practice could be bleeding money without you ever knowing.
Personally, I briefly had a front office staff person that would get a cancellation in the book and never take out the patient from the schedule. To me, it looked like a no-show when in actuality it was an open slot never filled. According to the employee, "who cares? My doctor lives in a nice house, drives an expensive car, and goes on great vacations." On the other hand, and I hope I only speak for a few, if your staff knows things that aren't kosher in your practice, they can hold you and your practice ransom.
Jack Ressler, DPM, Delray Beach, FL
08/11/2021
RESPONSES/COMMENTS (MEDICAL-LEGAL) - PART 1B
From: Jack Ressler, DPM
You are allowed to get paid for your services from Ciox. Just make sure you send them an invoice for this time-consuming service. $30-50 per chart is reasonable. Do not take the time to copy and send your charts until payment is received. I got a request two weeks ago. They called my office and their number came up as SCAM!
I did fax them an invoice for my services. Did you hear from them? Moving forward I will only respond to a request via certified mail. I will explain to them that because their number comes up as scam, I need to have confirmation that they are who they say they are.
Jack Ressler, DPM, Delray Beach, FL
07/27/2021
RESPONSES/COMMENTS (MEDICAL-LEGAL) - PART 1B
From: Mark Spier, DPM
The real data from the CDC is: As of 6:30 PM CT on July 21, 2021, the CDC's website stated through July 19, 2021, Vaccine Adverse Event Reporting System (VAERS) had received 6,207 reports of death (0.0018%) among people who received a COVID-19 vaccine. Since more than 338 million doses of COVID-19 vaccines were administered in the USA, this data reflects a vaccination-death ratio of 0.0018%.The CDC’s website says, ‘Reports of adverse events to the (VAERS) following vaccination, including deaths, do not necessarily mean that a vaccine caused a health problem.
This is because the U.S. FDA requires healthcare providers to report any death after a COVID-19 vaccination to VAERS, even if it’s unclear whether the vaccine was the cause. Furthermore, a review of available clinical information, including death certificates, autopsy, and medical records, has not established a causal link to COVID-19 vaccines, says the CDC.
Mark Spier, DPM, Reisterstown, MD
07/26/2021
RESPONSES/COMMENTS (MEDICAL-LEGAL) - PART 1B
From: Gary S Smith, DPM
It seems that most people don't understand how the vaccine works. It is not a "vaccine". It is a therapy. It is like injecting Tamiflu. If the "vaccine" works, you can still get Covid and you can still spread Covid. You just won't get symptoms. "Vaccinated" Covid people are like "Typhoid Mary". They can spread the illness without even showing symptoms. If science was really a "thing" anymore, vaccinated people are the ones who would have to wear a mask.
It should also be noted that the CDC has recorded over 9,000 deaths and 500,000 "documented" adverse reactions to the vaccine. According to the CDC, 33% more people died from the vaccine the second week of July than died from Covid. Since the vaccine has come out, so many people have gotten blood clots and pulmonary embolisms, there is a shortage of the test tubes to collect blood for the D-Dimer test. If you require a patient or a staff member to get an experimental therapy and they die, can you be sued? You should be.
Gary S Smith, DPM, Bradford, PA
07/23/2021
RESPONSES/COMMENTS (MEDICAL-LEGAL) - PART 1B
From: Thomas Hooke, DPM
Denying podiatric medical care to patients based on their vaccination status has ethical (and probably legal) implications. (I'm not a lawyer so I won't discuss legality). While the targets of your policy would likely be those people who simply choose not to get vaccinated, the policy would exclude many pregnant women, pediatric patients, those who have had prior adverse reactions/allergy to vaccines or ingredients thereof, and those with religious or ethical objections. With the abundance of resources dedicated to screening and infection prevention now readily available to medical practitioners, this seems like more of a punitive policy than a precautionary policy. I don't know if that is the case, but on its face that is how it appears.
A recent column from your neck of the woods, by New York Times ethicist Kwame Anthony Appiah provides a good response to your question: "Once certain patients are committed to non-vaccination, however, you are not free to make decisions that could reasonably be viewed as punitive. You can certainly insist on their keeping away from the premises if they pose a genuine risk to others in your practice. But that shouldn’t be the case, given that your patients are mostly vaccinated (and your staff entirely so) and that you’ll presumably require unvaccinated patients to wear masks and practice social distancing.
When unvaccinated patients ask for an appointment, you can routinely offer teleconsultations (in circumstances where this is a medically sound option), explaining that, in your view, every trip puts them at further risk of contracting or transmitting infection."
Thomas Hooke, DPM, Bullhead City, AZ
01/19/2021
RESPONSES/COMMENTS (MEDICAL-LEGAL) - PART 1B
From: Robert Scott Steinberg, DPM
Thirteen months ago, we had not heard about SARS-CoV-2. By now, I am sure many of us are reading all we can to keep us, our families, and our patients safe. We are doctors and many people each day ask about the new COVID-19 vaccines. As physicians, we have an obligation to follow the science and not fall for wild and crazy conspiracy theories.
I am saddened that a colleague can rationalize their decision not to be vaccinated. Where are they getting their information? It seem illogical and dangerous. There is no shortage of accurate information about the COVID-19 injectable products.
Robert Scott Steinberg, DPM, Schaumburg, IL
01/18/2021
RESPONSES/COMMENTS (MEDICAL-LEGAL) - PART 1B
From: Name Withheld
I got my private clinic signed up for priority vaccinations with our 1st vaccination this Saturday at the hospital. This is exciting as we have been living in fear of getting sick from being exposed to patients on a daily basis.
In the post regarding "When Office Staff Refuse to Get Immunized", it was mentioned that one option is to reassign the staff that doesn't want to get immunized to non-patient duties. Unfortunately, my main medical assistant who can't be reassigned has refused to get the vaccination based on her religious convictions and what she's heard from her church. I have tried to show her the data and literature on the vaccination to no avail. Any ideas on how to persuade her to get vaccinated?
Name Withheld
01/15/2021
RESPONSES/COMMENTS (MEDICAL-LEGAL) - PART 1B
From: Corey Fox, DPM
I agree that there is little to be concerned about with liability. The bigger and more likely problem is what happens if this employee contracts the virus and tests positive. Now you have to shut your office for a week. You may also have to call all the patients that were in the office and had contact with this employee for 72 hours prior to his/her symptoms or positive test. It's a headache you don't need.
Corey Fox, DPM, Massapequa, NY
03/21/2019
RESPONSES/COMMENTS (MEDICAL-LEGAL) - PART 1B
From: Christopher Orlando, DPM
This is a conversation that should not be happening. The DEA license should be retained until the doctor is fully retired and out of practice. The cost in New York is $731.00 for 3 years (243.67 per year). This is nominal. The cost of membership in ABPM, ABPS, etc. is three times the cost. Why cheap out on a small number? Historically, we as a profession worked very hard to earn the right to have the DEA license. This was a long hard battle that was finally won in 1971. Prior to that, we could not write any prescriptions at all. Our profession has been climbing a steep hill (and gaining) for the past 100 years. Let's not give it back.
While we are on the subject of prescriptions, our DEA license allows for schedule 2, 2N, 3, 3N, 4, 5 medications. Therefore, if doctors are allowed by their DEA license to prescribe medical marijuana, each doctor would then make an individual decision as to whether to prescribe it or not. I would not want that decision taken away from me by those who would elect to decline to prescribe it.
Christopher Orlando, DPM, Hartsdale, NY
03/19/2019
RESPONSES/COMMENTS (MEDICAL-LEGAL) - PART 1B
From: Richard A. Simmons, DPM
Jack, I faced the same dilemma about eight years ago. I contacted our State of Florida Podiatric Licensing Board and was told it was not necessary. I contacted my professional liability insurance carrier and they were more than enthusiastic that it was not necessary. So, I have not had an active DEA for about 8 years. I could not tell you the last time prior to then that I wrote for a narcotic, but I do know that since I discontinued my DEA license that I have no longer been called by patients in acute pain that could “only be resolved by Oxycontin, etc.” Save yourself time and money, but for peace of mind call the Licensing Board and your insurance carrier to get their 2019 opinion.
Richard A. Simmons, DPM Rockledge, FL
03/15/2019
RESPONSES/COMMENTS (MEDICAL-LEGAL) - PART 1B
From: Timothy P. Shea, DPM
One of your primary responsibilities as a professional business owner is the safety of your employees. Inappropriate behavior, such as language, physical activities, or any actions by patients, or anyone else, which you or your staff deem inappropriate is immediate cause for dismissal from the practice. My office manager is an ex-ER nurse and she does not tolerate anything, even over the phone, that falls into this category.
There is a fine template available from PICA Insurance for dismissing patients. We use the term "inappropriate action" in the letter to explain the reason for being let go. There is no second chance, and I have had a few call backs to request an opportunity to make amends to no avail. Your staff must feel safe in your work environment. Fortunately, this does not happen that often. I recommend you take immediate action in this matter.
Timothy P. Shea, DPM, Concord, CA
10/20/2018
RESPONSES/COMMENTS (MEDICAL-LEGAL) - PART 1B
RE: Requests to Trim Fingernails
From: Bryce Karulak, DPM, Charles Morelli, DPM
I truly think we are hyper-focusing with respect to trimming patients' fingernails. I am willing to bet that if anyone of us cut a patient's fingernails and went to the majority of the PCPs in our respective areas, they would not care and even say, "Great!"
Where this conversation should really focus on is enhancing our scope. I work in Texas and the law for podiatry basically reads, "A podiatrist may treat...
Editor's Note: Dr. Karulak's extended-length letter can be read here.
My question is very simple and I look forward to hearing from our legal scholars. Why is it that anyone can trim a fingernail but a podiatrist cannot? Why was my wife able to trim our daughter's nails? Why is a granddaughter not placed in peril if she cuts the nails of her grandmother in a nursing home? These examples are endless. Why might this not be covered under the Good Samaritan law which "provides basic legal protection for those who assist a person who is injured or in danger." I once had to pry open the hand of a patient in severe contracture, only to find a nail that was on the verge of puncturing his palm. Does that qualify him as being in "danger"? I submit to you that it does.
Charles Morelli, DPM, Mamaroneck, NY
10/12/2018
RESPONSES/COMMENTS (MEDICAL-LEGAL) - PART 1B
From: Paul Busman, DPM, RN
Like Dr. Morelli, I would very occasionally trim a patient's fingernails. These were generally patients that I had treated for a long time, had fingernails that were already pressing into their skin, and had severe disabilities. This made them unable to go to a nail salon. Some had such severe finger contractions that a nail salon would not likely want to treat them. Yeah, I know, scope of practice, liability, blah, blah, blah. I just didn't have it in me to refuse such a simple request which I was eminently qualified to fulfill. I never once had a problem doing this, just very grateful patients. Not that it legally meant anything, but I always told patients that their podiatry treatment was over, but I was cutting their nails as a friend might do. They got the message.
I never did treat warts on a patient's finger or any other area but the foot. However, I did tell them that if the warts on their feet were cured, there was a good chance that the warts would all go away. Know what? In a fair number of cases, that actually happened. Also, if I was treating a patient with some home applied remedy, e.g. Sal acid under occlusion, I'd point out to them that if they went to a dermatologist for their other warts, he/she might well prescribe a similar treatment for their other warts, wink, wink.
Paul Busman, DPM, RN, Frederick, MD
10/11/2018
RESPONSES/COMMENTS (MEDICAL-LEGAL) - PART 1B
RE: Requests to Trim Fingernails (Maryann Trivlis, DPM)
From: Charles Morelli, DPM
While I completely appreciate and understand Dr. Block's measured and legal response to this query, part of me is in complete agreement with him but the other part is rolling my eyes at this. While a podiatrist is limited in scope (which does not include the trimming of fingernails), and medical malpractice does not cover these treatments, please don't tell me that a medically trained podiatrist who went through 3 years of medical and surgical training who is now a doctor and/or a surgeon would say no to an incapacitated and frail senior citizen who asks you to help them cut their fingernails.
Back when I made home visits, I did it whenever I was asked. In my heart I could never say no. In my private practice, I have stroke patients, or patient afflicted with Dupuytren's who are unable to do it and have nails that are on the verge of breaking the skin of their hand and their wife or husband would ask (sometimes plead) for it to be done. How could you possible say no. At least I could never and still don't. Anyone ever treat a wart on one of your patient’s fingers?
Was I out of scope and was I opening myself up to the possibility of a malpractice case when they could have gone on to a massive fingernail infection and lose their finger or arm? Yes, I was, but my odds of hitting lotto or being struck by lightning were better than that. If you fear this, then just don't do it.
Charles Morelli, DPM, Mamaroneck, NY
10/10/2018
RESPONSES/COMMENTS (MEDICAL-LEGAL) - PART 1B
From: Elliot Udell, DPM
Yes, hardly a month goes by when a patient does not ask me to cut his or her fingernails. On Friday, another tenant in our medical building came in an asked me to cut one of his fingernails. I refused. I still remember one of my professors at NYCPM, over thirty years ago, boasting to the class at what a good deed he did for an indigent patient by cutting her fingernails. The problem is that in most states, it’s against the law. Dr. Block said it well when he said that such an action could subject a podiatrist to professional discipline.
I see no reason why our local state societies should not push for legislation which would allow podiatrists to cut fingernails but until this happens, we need to refuse.
Elliot Udell, DPM, Hicksville, NY
09/24/2018
RESPONSES/COMMENTS (MEDICAL-LEGAL) - PART 1B
From: Donald R Blum, DPM, JD
When a complaint is filed with TSBPME/TDLR, Name Withheld should have been notified of the complaint. Assuming it was from a patient, you would have received a letter requesting a copy of chart notes and x-rays (at your expense). At that point, you would have been made aware of who was the complainant. At that point, you have a limited [time] to forward the information to the TSBPME/TDLR.
Typically, your Medical Liability Company (I know PICA offers this service/benefit) will offer a defense for board complaints, or you can try to resolve this yourself. My issue to you is whether the information about the board complaint is whether it come from the National Practitioner Data Bank or from the TSPME/TDLR? Did you tell the hospital that a complaint had been filed, the nature of the complaint, and that it had been resolved with finding the complaint showed no merit? You might consider going the NPDB website and do a self-search. If there is incorrect information, see if they have a mechanism to correct that faulty info. Did the NPDB show that the complaint was resolved finding no merit and was dismissed?
My recommendation has always been to send a letter to the TSPME/TDLR requesting a copy of the complaint with allegations filed with the board.
Donald R Blum, DPM, JD, Dallas, TX
07/19/2018
RESPONSES/COMMENTS (MEDICAL-LEGAL) - PART 1B
From: Elliot Udell, DPM
There is a larger elephant sitting in the living room. When we use our e-prescribing tools, they automatically let us know what medications the patients has been prescribed by all of the patient's doctors. On the one hand, it is good because it would alert us if there is a dangerous drug interaction, even if the patient does not remember what medications he or she is taking. On the other hand, this represents an invasion of privacy and confidentiality.
Does this mean that any of us can punch in the name of any patient and find out what medications he or she is taking? What if a patient has a history of an embarrassing medical condition such as a sexually transmitted disease and does not want, "Dr. Jones" who is also a family friend to not know about that episode in his or her life? Don't the HIPAA laws protect this aspect of patient privacy?
Elliot Udell, DPM, Hicksville, NY
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