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08/21/2023
RESPONSES/COMMENTS (NON-CLINICAL)
From: Jeffrey Kass, DPM
8) “This service is not covered by this type of provider” I’m sorry, but if I am performing a service that I am licensed to do and within my scope of practice, then I should get paid for the service.
9) Inconsistent payment practices by insurance companies. How is it possible to bill an insurance company the exact same CPT codes and get paid different amounts each time? What about the insurance company deciding to halve payment if you bill an E/M and procedure code even when they are unrelated? Why should multiple procedure codes keep getting halved? You’re saving the insurance company money by not going to the operating room multiple times….
10) Why is it that if a podiatrist tries to get an orthotic covered, they can be told “it’s not covered” but when an orthotist or chiropractor puts in the claim, they are paid? Is the chiropractor more of an expert in orthotic treatment?
I believe the 10 items listed are some of the most problematic problems facing podiatry. The longer it takes to solve them, the quicker will be our demise. Increasing volume to make up for lost revenue due to the above problems is NOT the answer. You should not have to work harder and kill yourself to make a living. The profession needs to level the playing field with insurance companies. The profession has some very bright minds. Hopefully, together we can think of possible solutions.
Jeffrey Kass, DPM, Forest Hills, NY
Other messages in this thread:
07/01/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2
RE: Observations on the Changing Face of Medicine
From: Elliot Udell, DPM
I have a patient who is a soon-to-be retired psychiatrist. Whenever he would come into the office, we would have discussions on many topics not related to psychiatry or podiatry. He was very well aware of all facets of general medicine. If I asked this physician a medical question, he knew the answer. He later told me that he works one day a week in the ER doing emergency medicine and this helps him keep up with the entire medical field. In another case, my former GI specialist who just retired was able to comment with interest and expertise on any medical issue aside from the GI system.
I am now faced with seeing a whole new battery of young specialists in different fields and if I ask them a question outside their specialty, their answer tends to be, "It's not my field, go to an appropriate specialist." I am seeing more and more of this happening and some of these doctors are board certified in internal medicine and if the question does not directly relate to their subspecialty, the wall in the room can give me a better answer.
As a podiatrist, this may be good. We are specialized and only responsible for the foot, and so many other young specialists seem to have developed amnesia to all aspects of medicine other than their own narrow specialties. Perhaps the degree given to these physicians should not be an MD or DO but for example, "doctor of orthopedics or doctor of oncology, etc. Being a doctor of medicine is becoming less and less relevant in today’s practice.
Elliot Udell, DPM, Hicksville, NY
07/01/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1
RE: Has APMA Appointed Future Action Strategists?
From: Lawrence Rubin, DPM
At all times, healthcare professional organizations responsible for public outreach and relations usually have appointed future actions strategists. These qualified persons constantly monitor the standing its members have in changing aspects within the healthcare marketplace, including any significant changes in reimbursement issues.
I have been a member of APMA since 1958, and I am hoping that the APMA has done now what it has done in the past by appointing qualified strategists during these rapidly changing times (such as was done prior to change of the name of the profession from chiropody to podiatry). If it has, these strategists are realizing that the quickly advancing Medicare spearheaded transition from fee-for-service reimbursement to value-based care (VBC) is already devaluing payment for elective, "non-life threatening” surgery, and it is increasing the reimbursement value of prevention and chronic disease management E/M services. In podiatric medicine, chronic diseases include, but are not limited to diabetes peripheral neuropathy (DPN) and peripheral artery disease (PAD).
I am concerned about this because recent board certification discussions that appear to ultimately put, "most of all of podiatry's eggs in one surgery basket" could, to say the least, be counterproductive for the profession of podiatry.
Lawrence Rubin, DPM, Las Vegas, NV
06/27/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2
RE: A Rose by Any Other Name…
From: Rod Tomczak, DPM, MD, EdD
I hope all who read the letter by ACFAS and APMA have also looked at the history of the resolutions and position papers. It seems that in 2020 someone came up with the idea that if students of podiatric medicine could pass USMLE, they should be classified as physicians.
Out of the right side of their mouths, the MD officials are pushing our students to take the USMLE, and out of the left side, they are saying MD and DO passers of the USMLE can call themselves “physicians.” What seems very odd is that DOs can still take their COMLEX exam and be licensed as physicians.
This whole ploy is the biggest example of obfuscation I have ever seen. AOFAS would rather partner with Reiki practitioners than...
Editor's note: Dr. Tomczak's extended-length letter can be read here.
06/27/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1
RE: Podiatrists Self-Identifying as" Dr." or "Physician"
From: Carl Solomon DPM
Putting aside the discussion of whether or not podiatrists are physicians, I’d like to express some thoughts about how we address ourselves in that context. I can hardly recall an instance in which one of my MD/DO friends addressed him/herself as “physician”. When asked, or introduced, it’s “I’m an oncologist, orthopedist, rheumatologist, general surgeon…”, whatever. My dentist friends aren't too proud to be identified as a dentist...perhaps when appropriate, oral surgeon. Not physician.
And when I see the use of the term “Dr.” written in front of somebody’s name without other explanation, almost without exception, that’s a de facto acknowledgement that “I am not an MD”. This was personified on the sign-in sheet at one of my hospitals’ Dept. of surgery meetings. Everyone signed in simply with their name, with the exception of two, each of whom signed “Dr. Xxxxx”. You can guess…
A podiatrist may achieve some level of recognition by assigning him/herself the title of "Dr." or "physician", and the inference is that it represents being an MD. But oftentimes once the details come out, the concealment of the identity as a podiatrist makes it apparent that there is a low level of self-esteem associated with such identity. So whatever special recognition may have been achieved by initially identifying as a Dr. or physician, is actually negated. On the other hand, if one is humble and is acknowledged by another party as being a doctor…podiatrist, the level of recognition will remain high. If you can’t take pride in being a podiatrist, you should have spent the time and effort doing something else!
Carl Solomon, DPM, Dallas, TX
06/26/2024
RESPONSES/COMMENTS (NON-CLINICAL)
From: Stefan Feldman, DPM
I wholeheartedly agree with Dr. Ribotsky about forming a cancer registry for podiatrists. I too, am a cancer survivor, finding out I have lung cancer following my retirement after 41 years of practice. I am a lifelong non-smoker and can only guess what the source of my cancer is, but I think of all the carcinogens I was exposed to during my working days. My advice to younger practitioners is to protect yourself from radiation exposure and assure the air quality in your environment is as free of carcinogens as possible. Check your homes and offices for radon, considered the leading cause of lung cancer in non-smokers, and also consider having a low dose CT screening scan of your lungs if over 50 years old.
Stefan Feldman, DPM, Spring Hill, TN
06/25/2024
RESPONSES/COMMENTS (NON-CLINICAL) -PART 2B
Dr. Ribotsky brings up an excellent point about developing a cancer registry within our profession. What becomes very concerning to me is the point he brings up about the dangers of podiatrists and their assistants breathing in nail dust, a known carcinogen. With all the OSHA regulations medical practices must adhere to, regulations regarding inhalation of dangerous nail dust does not seem to be a concern of OSHA.
I've been manufacturing and selling a nail dust extractor system for many years and I cannot begin to tell you the frustration I have when I see the infinite regulations physicians must adhere to while the nail dust produced by one of the most common procedures podiatrists do is not addressed. I have sold many vacuum units throughout the years but would conservatively estimate that 80-90% of podiatry practices doing routine podiatry do not incorporate nail dust extraction systems.
Dr. Ribotsky brings up an excellent idea about forming a cancer registry. Unfortunately, it may be an uphill battle when governmental agencies such as OSHA make demands on offices that are borderline ridiculous, while known airborne carcinogens such as nail dust go completely unregulated.
Jack Ressler, DPM, Boca Raton, FL
06/25/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1
RE: AI and Podiatry
From: Lawrence Rubin, DPM
As podiatry board certification matters are bringing the profession closer and closer to there being mainly surgery limited practices, we'd better figure out a way to combat present and future bad AI public information. Let's say a footsore person gives AI this question: "Where can I go to get this big, red, sore bunion taken care of?"
It surely will not be to the benefit of the patient or podiatric surgeon for the AI answer to be, "Go to the Walgreens store nearest you. Ask the pharmacist where you can find bunion shields to reduce pain and inflammation caused by shoes and also Tylenol for bouts of intense pain." Forewarned Is Forearmed. We have to prepare ourselves to deal with AI. It’s good to see that APMA will have a lecture on AI at its August meeting.
Lawrence Rubin, DPM, Las Vegas, NV
06/25/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A
From: Elliot Udell, DPM
Kudos to Dr. Ribotsky for suggesting that there be some way of tracking podiatrists diagnosed with some form of cancer. As a cancer patient in remission, this issue is very close to me.
The medical community is grappling with another issue. Patients with breast and colon cancer are now presenting at very young ages. One patient of mine had his first colonoscopy at age forty and discovered that he had stage four colon cancer. Another young woman in her thirties is undergoing treatment for breast cancer. Are these caused by unidentified carcinogens or are people discovering these conditions earlier in life because of testing and awareness?
Elliot Udell, DPM, Hicksville, NY
06/20/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2
RE: Tom Brady’s Formula for Success (Allen Jacobs, DPM)
From: Jeffrey Trantalis, DPM
During my residency, I was taught, “if you do good honest work, the patients and income will follow.” Too many practitioners practice for only the short-term and instant financial gain.
Jeffrey Trantalis, DPM, Del/ray Beach, FL
06/20/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1
From: Allen Jacobs, DPM
I suggest this article for all PM News readers.
Allen Jacobs, DPM, St. Louis, MO
06/06/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1B
From: Jack Ressler, DPM
Why pay someone thousands of dollars to evaluate your own practice when all they are going to do is look over your numbers without even making an in-person evaluation of your office? They will offer to come out and evaluate your practice but at an even higher price. You can save money up front and sign a contract with other companies that will charge you a percentage of your sale price but you are at their mercy and cannot control the extent at which they advertise your practice. Signing with one of these companies gives them complete control of the sale of your practice even if you find your own buyer. I doubt they will give you exclusions.
Who better to value your practice than yourself? It is you who know your patients, staff, physical office set-up, demographics, and numbers better than anyone. The valuation of your practice comes down to one simple thing and that is the number a potential buyer is willing to pay. When I sold my main practice in 2016, I advertised it in the classified section of this forum. I did all of the work myself and paid a very reasonable amount for advertising and...
Editor's note: Dr. Ressler's extended-length can be read here.
06/06/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1A
From: Hal Ornstein, DPM
I highly recommend Mike Crosby, CPA of Provider Resources as a practice appraisal expert. He has performed this service for hundreds of podiatry practices and been doing this for many years. He is responsive, knowledgeable, and fair to all parties involved.
Hal Ornstein, DPM, Howell, NJ
05/21/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 3
From: Alan Sherman, DPM
A correction is needed in the Elliot Udell comment on concierge practices. I'm sure it was just a typo. The concierge doctor that is charging the $2,000 annual fee to 1,000 patients is making $2,000,000 before submitting their first insurance claim, not $200,000. Concierge practice magnificently improves the business model for running an internal medicine practice. It's brilliant.
Most limit their practices to no more than 600 patients ($1,200,000) so that they can provide good high quality service to them all. Here in Boca Raton, Florida, it has gotten hard to find an internist who is not concierge. This was all a solution for and a reaction to the poor service that high volume internists were generally delivering to patients before the concierge model evolved.
Alan Sherman, DPM, Boca Raton, FL
05/21/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2
From: Robert Kornfeld, DPM
I think it is really unfortunate that Dr. Gottlieb quotes a book written by an economist/psychologist who characterizes self-employment vs. employment in an overly-generalized way. This does nothing to honor or include the reality that every direct-pay doctor that I know is really happy since leaving insurance-slavery or corporate employment. I would think with all of our collective intelligence that we podiatrists would stop cowering in our boots and stand up like adults for our professional experience. At some point, you need to dismiss the naysayers, who only see things from a negative lens.
As adults, we possess the power of choice. With intention, commitment and consistency, anyone who wishes to succeed in a direct-pay model will succeed. Dr. Gottlieb, it isn't fair to many of our colleagues out there who are miserable and read a post like this causing them to give up hope of achieving success and happiness outside of a system that exploits and abuses them. It feeds into fear and insecurity and has no place in these kinds of discussions.
I find it interesting as well as disturbing that not a single one of the naysayers here took the time to ask me or Dr. Roth exactly how we created successful practices and I'm certain they spent no time investigating the option. Dismissal comes from small-minded thinking. Success comes from an open mind, self-esteem, and an ability to shut out all the rhetoric of those who are too afraid to stand up to the monster that the system has become.
Robert Kornfeld, DPM, NY, NY
05/21/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1
RE: Podiatry/Chiropody and Surgery
From: H. David Gottlieb, DPM
Surgery has been part of podiatry's DNA since its founding. While looking through some old pictures, I found some I took of my uncle's 1933 graduation picture from the Illinois College of Chiropody and Surgery. l am happy to share this picture if anyone needs confirmation that Surgery was part of the College's name and our profession's scope. Additionally, if you review back issues of Chiropody Reports or its defunct successor Podiatry Reports, you will also find many articles regarding surgical procedures of the foot. They may not be talar-calcaneal fusions, etc., but surgery has been a part of the average chiropody/podiatry practice from the beginning.
The concept of pay at time of treatment is also not new. Back then, medicine of all types was cash only. My father, who joined his brother's practice in 1943, has related to me that he would co-sign bank loans for his surgical patients. He rarely if ever had a default since the patients were so grateful that their pain was gone.
What's old is again new. I believe that medicine and surgery in the U.S. should be practiced along the model created by the Veterans' Health Administration. Call it the Civilians' Health Administration, dispense with the insurance companies as well as all other government-run health entities. Pay us a fair salary, reasonable working hours, evidence-based treatment protocols. Cash-only could still exist and even thrive for those with the knack for it.
H. David Gottlieb, DPM, Baltimore, MD
05/20/2024
RESPONSES/COMMENTS (NON-CLINICAL) -PART 3B
From: Steven E Tager, DPM
Reflecting on numerous comments in this thread, I offer this as it may be of benefit to those in need. Altruistic as it may be, at least for me, the desire to help others along with a little prestige (at the time) may have been the prime motivation for entering medicine. That, along with my own foot and back issues led me to a podiatrist who absolutely motivated me to pursue a career in podiatry. Podiatry, allopathic medicine, dentistry or whatever, all have experienced the tyranny of the insurance industry. Strength in numbers (and I mean $$) by the carriers have manipulated us (collectively all medicine and dentistry) as well as our patients, into the current system using everything and anyone possible to accomplish increased profits. Their greed and unbridled aggression for the almighty dollar has squeezed the life out of our collective private practices.
Recently retired, I reflect on my 56-year journey in podiatry. Successful? Yes, I certainly think so. How and Why? Early in my career, I met two physicians who had a profound effect on...
Editor's note: Dr. Tager's extended-length letter can be read here.
05/20/2024
RESPONSES/COMMENTS (NON-CLINICAL) -PART 2
RE: Podiatrists as Gatekeepers
From: Daniel Chaskin, DPM
Some internists perform physical evaluations including ordering and interpreting blood tests. If a systemic disease is found, an internist can refer to a cardiologist, nephrologist, or appropriate specialist. The internist can be sort of like a gatekeeper who refers. Podiatrists can do the same regarding any systemic disease with podiatric findings such as foot edema, brittle toenails, etc.
Daniel Chaskin, DPM, Ridgewood, NY
05/20/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1
RE: Employed vs. Self-Employed Doctors
From: H. David Gottlieb, DPM
I recommend everyone reading this to also read a fascinating book by the Nobel Prize winner in economics - author Daniel Kahneman. The book is called Thinking, Fast and Slow.
There is a relevant passage regarding the statistical likelihood of financial success, a topic currently being debated here. I quote from page 257: "More generally, the financial benefits of self-employment are mediocre: given the same qualifications, people achieve higher average returns by selling their skills to employers than by setting out on their own. The evidence suggests that optimism is widespread, stubborn, and costly."
One should keep this in mind before setting out on their own.
H. David Gottlieb, DPM, Baltimore, MD
05/20/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 3A
From: Elliot Udell, DPM
Concierge practices are not always direct-pay practices. My doctor flipped his practice into a concierge practice. The deal is you pay an annual fee for the honor of being a patient but have to pay or have your insurance pay for each visit. The annual fee may be 2K a year. If the doctor has 1,000 patients in the practice, the doctor makes $200,000 a year before turning the key in his door. The rest is gravy.
I visited an eye center for a cataract procedure. They let me know that my insurance would cover the procedure, but the laser they use to open the capsule would cost me 2K out-of-pocket.
Elliot Udell, DPM, Hicksville, NY
05/17/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1
RE: Is the Limited License of Podiatric Physicians Costing the Healthcare System More Money?
From: Bret Ribotsky, DPM
I had an opportunity this week to attend a pharmaceutical-sponsored county podiatric meeting here in South Florida, and the speaker was from out of state, a well known expert, discussing wound care grafts to apply. The lecture showed multiple pictures of completely or almost completely granulated wound beds to which they were applying a placenta graft tissue weekly at $2,500 per application, up to a total of $25,000 per application. When I queried why not just put a split-thickness skin graft over this wound, I learned that it was not within the podiatric license in the state in which this person practiced.
This got me thinking, is our limited license actually costing the system more money because of the inability to apply all the best medical practices by limitations of licensing? I know that while I practiced, I often would apply a split-thickness skin graft on a fully granulated wound bed. I was quite happy with then using additional products as needed, if necessary, What do others think about using these expensive grafts where the company makes all the money and the doctors do not?
Bret Ribotsky, DPM, Fort Lauderdale, FL
05/17/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2
From: Robert Kornfeld, DPM
Since this thread is still going, I would like to bring up a really important point that Dr. Meisler glossed over. Patients coming from these concierge practices were willing to pay directly when they came and were "surprised that they did not have to pay at the time of their visit." That should tell you something about the value they are experiencing in a direct-pay practice. That's number one.
Number 2, I agree with Dr. Meisler that eliminating poor payors will always make room for more value in the practice. However, it is important to note that as long as you continue to accept insurance, you will always be fighting an uphill battle. You will need to see a high volume of patients which means a large office, large staff, and high expenses. You will still have to navigate the slippery slope of...
Editor's note: Dr. Kornfeld's extended-length letter can be read here.
05/10/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1B
From: Richard M. Maleski, DPM, RPh
The recent thread in this forum on the future of podiatry has been extremely interesting and thought-provoking, with the most recent emphasis on the pros and cons of direct pay versus the more typical insurance dominated practice model. Let's not lose our historical perspective on this. Back in the 1960s, with the advent of Medicare, everything in healthcare changed. Prior to that, virtually all practices were direct pay, and the only insurance coverage was Major Medical, sometimes referred to simply as "hospitalization." When Medicare came around, our profession clamored to be included.
There are colorful stories of the behind closed doors antics that went on inside politicians' offices to assure that podiatric services would be covered. Since then, any time there has been a change, such as the emergence of managed care, we, along with every other medical group have done everything possible to keep ourselves included. And by being included in this payment model, we have been able to expand our status within...
Editor's note: Dr. Maleski's extended-letter can be read here.
05/07/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1B
From: Kathleen Neuhoff, DPM
It is unfortunate that local providers turfed their patients to Dr. Tomczak. However, in our area, this kind of turfing is rampant among those who accept insurance. Most of our local Latino population does not have insurance and many providers will not see them at all.
Ironically, when I accepted insurance, I was taken to task by the administration of our local hospital because I gave a significant discount to all religious leaders (rabbis, priests, ministers, nuns, etc.). I was advised that I was in violation of the contracts with my insurance carriers and had to “cease and desist”. Now that I have no contacts with insurance companies, I have restored these discounts. I also see large numbers of patients who have no insurance and am able to provide care for them at a cost they can afford.
Some of these patients are very sad. For example, Wednesday I saw a gentleman who had had an ingrown nail for months. He had been unable to find anyone to treat him until the local” free” clinic sent him to me. He is an uncontrolled diabetic and had osteomyelitis of the entire distal and part of the proximal phalanx. I had him admitted to the hospital which will end up eating the cost, and I will probably need to amputate at least his hallux. We have failed this patient at a huge cost to him and to our healthcare system. I do not think this is an issue of self-pay vs. insurance providers. It is a loss of the patient care mentality which should guide all of us.
Kathleen Neuhoff, DPM, South Bend, IN
05/07/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1A
From: Greg Amarantos, DPM
I find it interesting how a post can be interpreted from a different lens and diametrically opposing conclusions are reached. In reading Dr. Tomczak's response to Dr. Roth, I read Dr. Roth's post differently.
While we should believe we are providing the best possible care, we have to face the facts; in private practice, our treatment protocols are at least partially driven by the insurance company policies. I do not read any impugning of the profession. Dr. Roth should believe he is providing the best care, as should you and I. Cash frees the practitioner from the shackles of the insurance company policies. Think of the man hours used on "meaningless use/MIPS" and the like. Dr. Roth reminds me that medicine made a deal with the devil years ago and...
Editor's note: Dr. Amarantos' extended-length letter can be read here.
04/23/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2
RE: The Future of Podiatry - Part 2
From: Allen M. Jacobs, DPM
As we move forward (I should say you, as I'm on the 18th green and putting out), there must be a realistic examination of the future of medicine. As corporations and healthcare institutions continue to take over medical care, and insurers evaluate our care, the bottom line is cost-effectiveness. This is a major reason why NPs and PAs are replacing MDs and DOs as independent healthcare providers. This is a driving force for pharmacists beginning to provide healthcare. It is a driving force for urgent care centers replacing emergency departments, surgical centers providing services; we can site example after example.
Ultimately, insurance carriers want the least expensive medicine provided, whether it be testing, office fees, drug choice, or procedure selection. Industry, such as corporate-driven medicine, to the contrary, wants you for profit. You are evaluated by industry first and foremost by the profit you generate. The conflict between industry and...
Editor's note: Dr. Jacobs' extended-length letter can be read here.
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