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05/05/2023
RESPONSES/COMMENTS (MEDICAL-LEGAL) - PART 2
From: Michael M. Rosenblatt, DPM
I recently read on PM News that a "training course" is now required by DEA for prescribers to get registered or renew. I wonder if one of you can respond about this "training" who has experienced it. I don't want to jump to conclusions, but I assume that most of it is delegated to describing the "craftiness" of addicts' attempts to get prescribers to get them what they want. The rest of the experience is most likely used to demonize prescribers and make them feel "responsible" for the epidemic of drug abuse. But I could be wrong. What I would rather suggest more appropriate is for DEA to explain why they do not make more of an effort to prevent illegal drugs from the Southern borders entering the US.
Also, I would like DEA to make an effort to control drug access to the very large cadre of homeless populations in various US cities. DEA turns a blind eye to this. It is much easier to demonize prescribers. I don't want to make this a political discussion, because addictive drugs do not just affect one political group.
But I have a feeling that if a prescriber makes a public comment like this, they can "expect" the DEA to come down on them. So, if you prefer not to respond, I don't blame you. They can try to retract my DEA registration, but I have the freedom to write because I have none. There are some advantages to retirement. Free speech may be one of them.
Michael M. Rosenblatt, DPM, Retired, Henderson, NV
Other messages in this thread:
01/10/2024
RESPONSES/COMMENTS (MEDICAL-LEGAL) - PART 2
From: Elliot Udell DPM
Dr. Roth says it all when he states that in his state, California, podiatrists are allowed to perform thigh biopsies for the sake of diagnoses. He also feels that if podiatrists take training, we should be capable of doing spinal implants to control lower extremity pain.
Dr. Roth is correct when he says that DPMs are more than capable of doing a spinal implant and thigh biopsy, with proper training. Most of us do far more intricate surgical procedures on the lower extremity. The major issue for all podiatrists is that we need not forget that our scope of practice is governed state by state, not by capability but by anatomic restrictions. We can and should do a biopsy of a suspicious lesion that presents on the foot. We legally cannot biopsy that same-sized lesion if it presents on the patient's back even though it would be essentially the same procedure.
The bottom line for all of us is that before doing any procedure which is above the lower extremity whether it be a thigh biopsy, spinal implant, or whatever, we must check with our local state authorities to ascertain whether that particular procedure is within the scope of our practices in the state where we practice.
Elliot Udell, DPM, Hicksville, NY
01/09/2024
RESPONSES/COMMENTS (MEDICAL-LEGAL) - PART 2 B
From: Allen Jacobs, DPM
I am hopeful that the comment by Dr. Roth, in which he suggests that he would place a spinal cord neuromodulator in a patient with foot or ankle neurological pain, was submitted in humor. If a patient has a drop foot from L4-L5, would he perform a decompression surgery with fusion? What about an anterior cerebral artery aneurysm affecting only the leg and foot, or an aortic aneurysm causing blue toe syndrome or digital infarction? Is Dr. Roth prepared to treat potential complications such as spinal hemorrhage?
By the way, Dr. Roth, I suspect the placement of a spinal neuromodulator may not be comparable with your no insurance cash-only practice you profess to have mastered. You completed a non-ACGME approved podiatry residency, which you believe provided you with adequate training to place anything in a spinal cord? Please tell us you were joking.
Allen Jacobs, DPM, St. Louis, MO
01/09/2024
RESPONSES/COMMENTS (MEDICAL-LEGAL) - PART 2 A
From: Richard J. Manolian, DPM
Assuming you can do a thigh biopsy in California, is that the best place to do a biopsy for diagnosis of peripheral neuropathy? The answer is no. Next question is when you implant this device, completely out of the scope of your practice, will your malpractice carrier cover you? The answer is no.
Again, I ask when you post such things, why would a patient pay out-of-pocket for this in your office when an actual pain specialist or neurosurgeon will be covered by their insurance? The answer, well you get it by now. If I’m wrong, somebody please elucidate!
Richard J. Manolian, DPM, Boston, MA
05/23/2022
RESPONSES/COMMENTS (MEDICAL-LEGAL) - PART 2
From: Thomas Clark, DPM
There are a variety of online payroll solutions that will create 1099s for a relatively low cost. Our office uses Patriot Software to create the 1099. They will file the 1099 electronically for a nominal fee. This is a great solution to a very irritating issue.
Thomas Clark, DPM, Lebanon, PA
04/11/2022
RESPONSES/COMMENTS (MEDICAL-LEGAL) - PART 2
RE: Difficulty for New Podiatrists to Get into Provider Networks
From: Joe Dahlin, DPM
Regardless of whether you're a recent residency grad or a seasoned practicing podiatrist, it is only going to get worse for private practices as they “negotiate” rates or worse yet fight and claw just to be accepted into the “insurance network”. This was a primary reason I chose to open a cash-based practice. After experiencing mass frustration “negotiating” with my local insurance networks and knowing it would only get worse, I made the decision to forgo insurance altogether. Only 6 month into practice, and already my volume and revenue is beyond what expected.
Best of all, I control current and future pricing for patients and subsequently reimbursement for myself. Further, I’m seeing substantially fewer patients, spending more time with them, and providing a higher quality of care than ever before. I encourage all younger podiatrists to truly consider going cash-based. There are only a small subgroup of potential patients who will enjoy and utilize this practice model, so the sooner a physician goes cash-based, the better chance they have at acquiring this patient subgroup and carving out their future career which cannot be dictated or controlled by large insurance companies and hospitals.
Joe Dahlin, DPM, Grand Junction, CO
01/16/2020
RESPONSES/COMMENTS (MEDICAL-LEGAL) - PART 2
From: Paul Busman, DPM, RN, Vladimir Gertsik, DPM
I wholeheartedly agree that you should never let a patient dictate what procedure and/hardware should be used for any surgery. This is particularly true if the procedure and hardware are not familiar to the surgeon. Tell the patient what procedure you recommend and are really good at. If they don't like that (because they saw something they like better on the Internet?), send them on their way.
Paul Busman, DPM, RN, Frederick MD
I find it bizarre for a patient to request such a specific thing. If the patient is so knowledgeable, he or she should perform the surgery on himself or herself. You should send the patient to the author of the YouTube video. It is certainly appropriate to have a discussion about some aspects of the surgery, but not to this level of specificity. A Seinfeld episode comes to mind, when Kramer was complaining about surgical retractors. Send this patient to the manufacturer of the plate, or anywhere else!
Vladimir Gertsik, DPM, NY, NY
03/19/2019
RESPONSES/COMMENTS (MEDICAL-LEGAL) - PART 2
From: Joel Lang, DPM
This actually happened to me and one of my staff members many years ago. There was this elderly man who engaged in inappropriate touching with a female assistant, particularly in a small whirlpool room where she offered him assistance removing his shoes and socks. She came to me after a number of incidents and while it made her uncomfortable, she tolerated it because she did not want to lose a patient for me. I was pleased that she brought it to my attention and I told her so. My immediate response was "I have many patients, but good assistants are hard to find. So, if one of you has to go, it has to be him."
I gave her two options: 1) Since she was mature enough and self-confident enough to speak for herself, I would allow her to speak to him directly and let him know that his behavior was unacceptable and would no longer be tolerated. 2) Alternatively, if she wanted me to speak with him, I would do so and transmit the same message.
In either case, if the patient was lost, so be it. My memory is that she chose the first option and I don't accurately remember whether the patient remained in the practice, but I think he did.
Joel Lang, DPM (retired), Cheverly, MD
07/09/2018
RESPONSES/COMMENTS (MEDICAL-LEGAL) - PART 2
From: Allen Jacobs, DPM
We have always charged and received $20 per chart for requested records. Our office has always obtained full payment; in advance, I might add. Never, ever have we encountered any difficulty. On occasion, any reluctance to pay has been overcome with a clear positional statement of our policy to the requesting organization. In my experience, Dr. Kesselman’s advice and counsel in PM News regarding this matter is correct.
Generally speaking, a contractual obligation to provide necessary documents does not stipulate that such obligations be performed at your expense. You should recall that your contract is with the insurance provider and is NOT with the reviewing organization retained for auditing. Many states, such as Missouri, have enacted regulatory stipulations for minimum payment to you per CHART and/or per page or BOTH.
Allen Jacobs, DPM, St. Louis, MO
11/07/2015
RESPONSES/COMMENTS (MEDICAL-LEGAL) - PART 2
From: Arthur E. Helfand, DPM
Dr. Musella asks, "What is the history of the rules for routine foot care and mycotic nail care? Are any other Medicare-covered treatments subject to similar rules?" May I offer two reading suggestions that are in the current literature: 1. When Routine Foot Care Should not be "Routine" Part 1, Podiatry Management, October 2012, pages 163-173 and Part 2, Podiatry Management, January 2013, pages 189-198. and 2. Medicare - An administrative Perspective, Chapter 24, Public Health and Podiatric Medicine, American Public Health Association, 2006, pages 335-353.
One also needs to go back to the original Medicare Law when we became a part of Medicare in 1965, including Section 1862a and the subsequent exemptions as regulations issued in 1970-1971, and 1984. You should find the information you are looking for in these documents.
Arthur E. Helfand, DPM, Narberth, PA
11/05/2015
RESPONSES/COMMENTS (MEDICAL-LEGAL) - PART 2
From: Bryan C. Markinson, DPM
The new Novitas LCD has been bantered about for weeks now. I have had conversations with DPMs in other states. They told me that their state associations and CAC reps are silent and non-responsive. The fact is that no one has a solid reliable interpretation of the LCD. It's time APMA solves the confusion immediately. I don’t mean that we should start a fight to change it yet; we just need to clearly know what it means. For my preference, it would be great if we were all suddenly forced to tell Medicare patients that treatment for cutting mycotic toenails, fungal or not, painful or not will be on a cash basis.
Bryan C. Markinson, DPM, NY, NY
11/02/2015
RESPONSES/COMMENTS (MEDICAL-LEGAL) - PART 2
From: Bradley Bakotic, DPM, DO
Recently, I sent a letter to our clients regarding a Novitas Local Coverage Determinant affecting the States of NJ, PA, MD. DC, DE, TX, CO, OK, AR, LA, and MS. Because there was some confusion regarding the missive, today I sent out an additional letter to clarify, and to provide the most current LCD number (the previous LCD was recently retired to accommodate for ICD10; however, the content was otherwise unchanged). The updated LCD number is #L35013.
Regarding the LCD contents, podiatric clinicians in Novitas jurisdictions should be aware that no lab testing is required prior to debridement (11720 / 11721) while patients are being treated for fungal nail infections, as long as the features of onychomycosis are present. Testing is only required when patients are not candidates for treatment, when treatment is unsuccessful (thereby requiring continued post-therapy debridements), or when debridements will be frequent and occur over a long duration (12 in a 24 month period).
A final point that should be made is that this LCD currently does not affect jurisdictions outside of the above listed states. Over the next year, however, it is exceedingly likely that it will be adopted by the other Medicare administrators. For this reason, physicians should check with their state’s administrator routinely.
Bradley Bakotic, DPM, DO, Alpharetta, GA
04/24/2015
RESPONSES/COMMENTS (MEDICAL-LEGAL) - PART 2
RE: Denied ABPM Eligibility Because of Semantics (Marc A. Benard, DPM)
From: Bryan C. Markinson, DPM
I have read the appeal by ABPM to the JCRSB regarding this disaster. The appeal letter was well crafted, reasonable, and truthfully re-iterates the reason why this unintended consequence took place. It also relates how affected residents making a certain choice at a certain time could in no way predict these consequences. They need immediate relief as the consequences are truly potentially devastating and limiting to their careers for ABSOLUTELY NO REASON. Certainly, none of them, from the moment they applied to podiatry school to the day they finished training, could ever plan for a position where their own profession would be hurtful.
Alan Tinkleman's response on the other hand was short, and curt; the only interpretation of which is "this is what you wanted" ...which is anemic, insulting, unfair and disgraceful, and further compounded by the remark about "no one" commenting in opposition. How can you comment in opposition to a rule for which the unintended consequence is not yet known? That is the meaning of unintended consequence.
No one in this field is more proud and grateful to be a DPM than me. However, this profession has wanted to cull the "cream of the crop" from the undergraduate world, and has wanted that since I entered the profession as a student. Well, we don't deserve their consideration. There, I said it!
Bryan C. Markinson, DPM, NY, NY
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