05/04/2022    Name Withheld

Urgent Care Center and Walker Boot Braces and DME Items

This past Friday, I saw a new patient for an acute
injury. He was referred by his friend, a prior
patient of mine, upon whom I had done bunion
surgeries. This new patient was seen three days
earlier at a local urgent care center, and was
correctly diagnoses with acute minimally displaced
4th and 5th metatarsal fractures on one foot,
fitted for a walker boot, dispensed crutches, told
not to walk on the foot and immediately follow-up
with an orthopedic surgeon.

The patient, a 75 year old male, presented with
crutches and an improperly fitted ankle height
pneumatic walker boot. The crutches were not
adjusted to his height and he had great difficulty
walking while trying to be NWB on the injured
foot.

He was given no crutch training at the urgent care
center, nor were there any instruction how to use
the boot, other than to stay off the injured foot.
His toes were protruding past the end of the
boot. The boot was too small for his foot (he
wears a size 11 shoe and was fitted for a Medium
walker). By the end of our visit, I dispensed a
properly fitting below the knee, non-pneumatic
walker and I adjusted his crutches properly for
his 6' 2" height.

However, he did not require to be NWB, so we did
some gait training and he was able to ambulate
with the new boot and did not need the crutches.
He said he was much better with the new boot and
with no crutches at all and walking on the foot
with the boot he had no pain.

The urgent care center will surely charge Medicare
for the walker boot, so I told him he would have
to pay me for my boot, and it would not be
billed by me to Medicare because they will only
pay for one boot in a 5 year period of time. I
had him sign a ABN form to keep in my chart and he
paid for the boot. For this patient, at least so
far, it was not an issue for him to pay me. I
also suggested that he return the first boot back
to the urgent care center (and ask for a receipt
of return) and tell them he can't use it and the
reasons why.

Here is my question: Why are doctors and nurses
and assistants at urgent care centers held to
lower standards than we, as podiatrists are, when
fitting and dispensing crutches and walkers, and
post-op shoes ? If they are allowed to dispense
these items, should they not have proper training
as we are required ?

This is not a unique occurrence. I have seen this
same situation before (not all the time) where
patients are improperly fitted with walkers, ankle
braces, post-op shoes and crutches and I have to
switch them out to proper sizes.

Are others out there seeing the same issue, and
how do you handle this, or am I alone here ?

Other messages in this thread:

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05/05/2022    Paul Kesselman, DPM

Urgent Care Center and Walker Boot Braces and DME Items (From Name Withheld)

The provider posing this question offers a very
valid question. In states where there are no
licensure requirements for dispensing orthotics
and prosthetics (the vast majority),
there are no regulations which restrict who can
fit and dispense OTC, custom fit or even custom
fabricated orthotics and/or prosthetics. Only
approximately 17 states have restrictions
requiring licensure regarding the provision of
orthotics and prosthetics. Medicare goes further
in requiring Facility Accreditation and Surety
Bonding for providers who are both not providing
devices to their own patients and who do not meet
the exemption requirements.

That being said, I advise my clients to do what I
did when in private practice, whether it was for a
foot orthotic or AFO, to go back to the original
dispensing provider in order to obtain a properly
fitted device. Should that fail, I would advise
the patient to return the device and contact
Medicare at the 1800 MEDICARE number and let
Medicare know the device did not fit and was
returned. This needs to be done within the return
policy which is mandated to be on the proof of
delivery form or warranty form (as per NSC
requirements). Similar protocols for MCR Advantage
Plans and third party plans should be followed. I
would not recommend adjusting someone else's work
because that could quickly become your nightmare.

In the end you want to satisfy your patients, but
they must be properly educated on the Medicare
regulations and they must take responsibility for
this by signing an ABN and paying you for your
DMEPOS and fitting is more than appropriate. You
can advise the patient you will file a first level
appeal for them as part of your commitment to
getting them to heal.


Should your patient taking the initiative with
dealing with the urgent care center directly fail,
there are multiple factors to consider, with a
multiplicity of providers at the center who fit
patients being one of many. Who at the urgent
center needs education needs to be identified and
that most certainly is for them not you to
identify. You also don't know what the patient(s)
may have refused to accept delivery on nor what
alternative choices the urgent care center may
have offered the patient.

There is also a delicate balance between getting
the patient initially fit correctly without you
upsetting a potential future referral source.
while you don't want to see patients get hurt and
you don't want to cut off a potential referral
source by being abrupt and rude. So handling this
the proper way by education and not being
adversarial is the way to pursue this. Should your
efforts prove fruitless, your patients could
always file a complaint with Medicare and provide
evidence of your charting that the device was not
properly fit. Taking photos in this instance is
recommended.

If you are in one of the states which requires
licensure to fit and dispense AFOs, such as Cam
Walkers, the likelihood is that the urgent care
center may be exempt from that rule because their
staff is comprised of licensed health care
providers (MD/DO/DPM, PA/NP, etc.).

Ultimately the urgent care center may not take too
kindly to your efforts to educate, but if handled
correctly, you may obtain
a referral source which more than offsets the
issues you present.

Paul Kesselman, DPM, Oceanside, NY