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11/21/2024
RESPONSES/COMMENTS (NON-CLINICAL)
From: Ivar E. Roth, DPM, MPH
Unfortunately, the medical billing rip-off is rampant in medicine and podiatry. I do forensic reviews and am privy to DPMs’ billing and I can tell you that 90% of the bills I review are toxic.
Recently a plantar fasciitis patient came to see me who had been treated by a local podiatrist. The patient was not getting any better and explained his treatment. He thought he would save money and went to an insurance podiatrist instead of me, a direct pay podiatrist first. Here is what happened. He was charged for a new office visit and x- rays were billed to his insurance. He was then told he needed to start shockwave therapy that was not insurance covered, and he was given stretch exercises. There was NO mention of an oral non-steroidal, orthotics, or a steroid injection. The shockwave therapy did not work; meanwhile he was in pain. He then was told that he should have orthotics and if that did not work, the DPM would try a steroid injection. He was told if that did not work, he would need surgery
Unfortunately, this treatment was about making money first and the patient last. It is truly unbelievable that there are docs out there ripping off not only the system, but their patients, and making their patients suffer at the expense of making an almighty dollar. Truly listening to this patient made me disgusted about the ethics of some of the younger doctors out there in practice.
Ivar E. Roth, DPM, MPH, Newport Beach, CA
Other messages in this thread:
12/21/2024
RESPONSES/COMMENTS (NON-CLINICAL) -PART 1A
From: Jon Purdy, DPM
I agree with Dr. Kesselman that people are far too undisciplined to manage their long-term care. The government is certainly not capable of that either, as can be seen with insolvency of Medicare and Social Security. The government is not a safety net, it is a burden on society. The government does not invest the monies, they spend it. And, at the end of life they keep YOUR money! In addition, instead of returning your money, they charge you more, with a 20% co-pay, annual deductible, increasing denials, and no free medications. Both of these programs can be taken from you should the government decide. How is that working for everyone?
What I was referring to has far too many details to go into on this forum, but suffice it to say, this would be one mandate I would be in favor of. The mandate to deduct and invest the monies until retirement, at which point a person would have millions. The other benefits of this are passed on as family wealth, a huge spike in the market and economy, as well as more money to spend as you see fit in retirement.
Jon Purdy, DPM, New Iberia, LA
12/21/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2
From: James DiResta, DPM, MPH
If there is one lesson to be learned from these recent blog entries, whether overtly stated or implied, and I might add from some of our most esteemed colleagues, it is the stupidity of suggesting that we ought to "stay in your lane". If podiatrists of my generation stayed in our lane, we would be nowhere. We have come this far because we were willing to buck the system and work to improve our profession beyond the instruction we received. I anticipated that those coming along behind me would expand our scope further and not be satisfied with the status quo.
If we fail to move this profession forward and expand our scope to practicing more general medicine, we will be extinct in a very short time. The walls are closing in on us. Why are we committing ourselves to being stuck in our lane? It is unthinkable that our 4-4-3 model of education has limited us to treating only the local manifestation of...
Editor's note: Dr. DiResta's extended-length letter can be read here.
12/19/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 4
From: Paul Kesselman, DPM
Once again, the insurance industry has sent the exact wrong message to the public. Rather than take this murder as a wake-up call to them to respond to the public's need for more transparency, they have chosen to insulate themselves even more. As Kevin O'Leary from Shark Tank said, "Putting up fences around headquarters and providing their executives with more security is not the message the public needs to see."
As for my friend and colleague Jon Purdy, his comment regarding Medicare losing money and allowing people to save money on their own to use for healthcare, fat chance that will work. Most people are not that disciplined that they can do that, and that was the whole purpose for Social Security and Medicare in the first place: To ensure that people in later life would have a safety net to provide to them.
The problem is that Medicare was not set up to be a profitable entity, but the Medicare Part C plans were set up to...
Editor's note: Dr. Kesselman's extended-length letter can be read here.
12/19/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 3
From: Robert Kornfeld, DPM
Dr. Jacobs’ definition of podiatry, should it be the majority opinion, will surely lead to the death of podiatry. If all we do is look at the foot, focus on the foot and treat the foot regardless of the underlying immune burdens (as if the foot is independent of the body it is attached to), we will surely be replaced by NPs and PAs in the coming years. We are already a profession that is slowly being usurped by these new professions. Dr. Jacobs and I are from the older generation that began the battle for parity through better surgical skills.
But will that sustain us? I say absolutely not. I feel that our schools need to provide more comprehensive training in what creates an inefficient immune system that is part and parcel of most of the pathology we treat. Are we not allowed to advance our skills once in practice? Or are we only allowed to practice what we learn in...
Editor's note: Dr. Kornfeld's extended-length letter can be read here.
12/19/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2
RE: All I Want is My Fair Share
From: Rod Tomczak, DPM, MD, EdD
“All I want is what I have coming to me. All I want is my fair share.” - Sally Brown in A Charlie Brown Christmas 1965
I’m not sure how I remember that quote from 59 years ago. Maybe a strange proclivity, or perhaps a suppressed prophetic tendency rearing its head at this most auspicious time of the year. The quote may be prophetic for our profession, maybe not. Regardless, we need to take a look.
After some critical introspection and meditation, I have come to the conclusion there are multiple podiatric phenotypes that cause us to scratch our heads and ask, “Quo tenditimus?” (similar to tendonitis but accurate as is) or “Where are we going?” Rather than use dentistry as an example, let’s use ophthalmology as...
Editor's note: Dr. Tomczak's extended-length letter can be read here.
12/19/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1
RE: Read the Fine Print
From: Gary S Smith, DPM
We were approached by a Rep from Samaritan Biologics, a company that supplies various biologic grafts. They presented us with a video and emails/text messages detailing that we would keep 40% of whatever Medicare approves for the material. We did order and apply a graft in the office. We were presented with a bill from Samaritan for 100% of what Medicare approves.
When we questioned this, the CEO called us and told us we missed the fine print where it says we pay 100% of what Medicare approves for the first 3 grafts in a month, THEN you get to keep 40% of the fourth! Obviously, nobody would order a second material from this company. I suggest anybody being approached by them to not purchase, or at least, read the fine print.
Gary S Smith, DPM, Bradford, PA
12/18/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2
From: Steven Finer, DPM, H. David Gottlieb, DPM
Dr. Jacobs is completely correct. MDs making half a million work their tails off. The real money people are the CEOs of drug corporations making fortunes. It is not made through salaries but by stock options. Read the listed groups and you will see the money made when these people pay pennies per share for their options.
Steven Finer, DPM, Philadelphia, PA
Fellow podiatrists seem to like to bitch and complain about their lack. Lack of income, lack of perceived respect, whatever. The only person who can change both your situation and your happiness is ... YOU. I suggest changing your situation or finding a good therapist.
H. David Gottlieb, DPM, Baltimore, MD
12/18/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1
RE: Definition of Podiatry
From: Allen M. Jacobs, DPM
What is the definition of podiatry? A podiatrist is educated at the didactic and clinical level to diagnose and treat disorders of the foot, and in some states, the ankle and lower leg. The willful misinterpretation of the limited scope of practice of a podiatrist by some DPMs does not justify the practice of general medicine by a podiatrist. Example: a patient presents to you with tingling and burning paresthesia. You rule out local nerve entrapment. You order electrodiagnostic studies. The studies demonstrate a peripheral sensory neuropathy. Or you perform an epidermal nerve fiber density study. The test is consistent with small fiber neuropathy.
Now what? This is not pathology intrinsic to the foot. Whatever the etiology, as a podiatrist, you are not educated to proceed with further...
Editor's note: Dr. Jacobs' extended-length letter can be read here.
12/16/2024
RESPONSES/COMMENTS (NON-CLINICAL)
From Jon Purdy, DPM
It goes without saying that this is a tragedy regardless. The other tragedy is the root cause of what led to this, and that started with the inception of Medicare. It is, and always was, destined to be insolvent. Medicare does not function as originally promised, and now is tinkering with the system, partnering with private plans. The not so unintended consequences are seen in everyday practice and patient care.
Can anyone name a program the government runs that is fiscally responsible and works well? If the working class were allowed to keep and invest the money the government takes from them their entire working lives, an individual would have a million plus dollars to spend as they see fit on their healthcare. This ownership inevitably necessitates responsibility. One would be able to afford their own insurance premiums and pass what is left to their own families. The government in all its wisdom has farmed out Medicare allowing for further corruption, as has been eloquently outlined numerous times by Dr. Kesselman.
Medicare effectively pulls millions of people out of the free market affecting the price and function of private plans. It is not subject to market forces such as they demand a quality and cost-effective product to stay in business.
Jon Purdy, DPM, New Iberia, LA
12/13/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2
RE: Healthcare Reform
From: Chris Robertozzi, DPM
The United States has been ranked as having the worst healthcare in the world in high-income countries, despite spending the most money according to the Commonwealth Fund report in 2022. As a physician, that is embarrassing. To find the best solutions that will make us the leader of healthcare in the world, the entire delivery of healthcare must be evaluated at the same time and everyone that has anything to do with the healthcare system must be involved. That would include: all national associations of those who provide healthcare in any manner, America’s Health Insurance Plans, National Pharmaceutical Association, American Institute for Medical and Biological Engineering, and patient advocate groups.
Unless everyone is at the table and understands each other’s issues, a long-lasting solution will not be possible. They have all been sent an invitation to join the initial Zoom meeting on February 5, 2025, at 4 pm EST to see how we can...
Editor's note: Dr. Robertozzi's extended-length can be read here.
11/27/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2C
From: Jack Ressler, DPM
I've been reading a few of the comments posted by fellow podiatrists addressing a query written by Dr. Roth. Next month will be two years that I have been retired so I can say I do not have any "skin in the game" concerning Dr Roth's query. There have been some strong negative and sarcastic comments posted by several podiatrists.
I cannot vouch for Dr .Roth's expertise about insurance companies but suffice to say, if PM News posted a poll question asking if podiatrists had the option of seeing patients on a cash basis versus taking their insurance, I think we all know what the answer would be. After practicing for over 35 years and having the headaches of audits, fair hearings, non-paid services, deductibles, and more, I know what my answer to that poll question would be!
Jack Ressler, DPM, Boca Raton, FL
11/27/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2B
From: Brian Kiel, DPM
I am confused. None of the treatments supposedly offered and/or performed by the “insurance“ podiatrist are unethical. I have used each of those treatments in the 50 years that I’ve been in practice, maybe not in the order, but offered and used, and when one treatment plan was unsuccessful, we would try another.
I’m also confused by Dr. Roth’s dismissal of the financial aspects of any one or all of these treatments. Does Dr. Roth not charge for any treatment he does and expect payment from the patient since he does not participate in any insurance plans. It seems to me that Dr. Roth’s anger is based on the fact that the patient went to another doctor. I find it helpful in treating a patient to know what was not successful when treated by another doctor. As others have said, none of us are 100% successful in treating any problem.
Brian Kiel, DPM, Memphis, TN
11/27/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A
From: Elliot Udell, DPM
Thank you Dr. Tomczak for showing us the article titled, "What’s New in Orthpaedic Rehabilitation”. The portion of the article on the use of dextrose prolotherapy was cited.
This therapy is by no means a new therapy, and reading the article cited, it did not seem to be superior to cortisone injections. The problem with prolotherapy is not whether it is efficacious or not. The problem is that many dishonest practitioners are overcharging for what amounts to an injection of dextrose. I had a young fellow many years ago who was going to one of these practitioners and was paying $600 for an injection. He was broke and could no longer afford it. I bought a bottle of the injectable for a couple of dollars and gave him the shots for free. He was a very happy camper. Although prolotherapy is not my first line of treatment, I have no problem using it if a patient really desires it and it is therapeutically indicated.
Elliot Udell, DPM, Hicksville, NY
11/27/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1
RE: Who Determines the Standard of Care?
From: Rod Tomczak, DPM, MD, EdD
The term "standard of care" has been bandied about recently in a few postings in PM News. One author seemed to impugn whether the standard of care had been breeched because a patient had sought treatment from another podiatrist rather than from the author because the author of the letter was in his humble opinion, the standard of care, and if you read between the lines, also the gold standard. That is an absurd assertion.
The standard of care, not the gold standard, is the level at which an ordinary, prudent professional with the same training and experience in good standing in a same or similar community under the same circumstances would perform. This is not the “average podiatrist since that would mean half the foot and ankle physicians would not qualify. The plaintiff must prove that the...
Editor's note: Dr. Tomczak's extended-length letter can be read here.
11/25/2024
RESPONSES/COMMENTS (NON-CLINICAL)
From: Stephen Doms, DPM
I recently had spinal fusion of lumbar 3-4-5 performed by an orthopedic surgeon. He saw me the morning of the surgery and then the next day in the hospital. The next time I saw him was 6 weeks later. (His PA removed Steri-strips after two weeks.)
Compared to other specialties, I think we podiatrists coddle our patients. Granted, I completed my residency 43 years ago, but this was my routine with bunion surgery patients: Surgery on Friday, bandage change on Monday, suture removal the next week, then a follow-up visit in four weeks and again in another month. I know I didn't make much money on the surgery because I saw the patient many times during the global period for free.
Stephen Doms, DPM, Hopkins, MN
11/22/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1D
From: Robert Maccabee, DPM
In Ivar Roth’s recent post, he claims "the medical billing (in his mind) is a rip off”... One of his 411 posts to PM News. Not exactly the guy I would expect to do forensic reviews regarding toxic billing. He claims to be out-of-network and his Concierge Podiatry and “SPA” giving mani and pedi treatments. This just doesn’t seem like the practitioner to be reviewing billings. So if a patient comes in, as he mentions in his post, don't use shockwave as it’s not covered via insurance - but you’re out-of-network and charging them even if they might not want an injection initially. I gather he’d nail them for orthotics even before attempting what he calls a worthless therapy program.
After, if I read correctly, an injection that didn’t work, prescribe an orthotic that for this guy didn’t work, but when all else fails, don’t attempt surgery but go to you (as you’re the be all and end all), but charge him out-of-network and call all this toxic. Really? Come on - sounds like a little B.S. to me from the guy who's promoting mani, pedis, facials, or what you call hydro facials and inject some wacky “Paincur” that he seems to have invented as the website has him as the inventor. I know of no real pain management “physician” who has ever heard of it, but I gather he's charging multiple visits for that. Really? and he claims other podiatrists are charging “Toxically”.
Robert Maccabee, DPM, NY, NY
11/22/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1A
From: Allen M. Jacobs, DPM
Dr. Roth expresses his "disgust" at the treatment of plantar fasciitis by a colleague. He opines that the "younger podiatrists" are motivated by money rather than patient well-being. He states that the patient consulted with an insurance covered podiatrist rather than "me", (that is) Dr. Roth. What was most disconcerting to me was the statement that Dr. Roth reviews anything for the purpose of making a judgment on the necessity of care and, hopefully not, standard of care.
Dr. Roth is critical of the utilization of ECSWT for the treatment of plantar fasciitis. In point of fact, while I personally do not employ ECSWT due to the general difficulty in obtaining insurance coverage for this modality, it is an acceptable and not-infrequently utilized modality for the management of plantar fasciitis. There is reasonable literature support for this modality in the management of...
Editor's note: Dr. Jacobs' extended-length letter can be read here.
11/22/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1C
From: Adam M Budny, DPM
I read this post earlier today and quite honestly I was perplexed, as I am one of the "insurance podiatrists" who I believe represent the majority of the profession, as opposed to a boutique/direct pay" podiatrist (which seems to be Dr. Roth's implied practice model?). I see nothing wrong with billing a new patient visit or x-ray as a diagnostic study. How else would a practice run if you did not bill new/established visits of one sort or another?
Specifically, in my experience and clinical practice, stretching exercises are actually the mainstay of management for plantar fasciitis, and all of my patients are given literature and a home exercise program (HEP) for performing this at their initial visit. Regarding shockwave therapy, this is also a well accepted treatment option per the American College of Foot and Ankle Surgeons Clinical Consensus...
Editor's note: Dr. Budny's extended-length letter can be read here.
11/22/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1B
From: Charles Morelli, DPM
I'd like to echo Dr. Roth's sentiment and experience when it comes to the fact that "the medical billing rip-off is rampant in medicine and podiatry." Yes, every profession has their bad actors, but sometimes you come across with a story that makes you shake your head. I'll try to be brief.
A patient was seeing the same podiatrist every 6 weeks, for over 22 years. He was treating her for a chronically ingrown nail, was cutting the corner of her nail, charging her the $25.00 co-pay and I imagine also billing her insurance carrier. She called one day for an appointment and asked to be seen as she was in pain, and felt it was an emergency. According to the patient, no matter how hard she pleaded, she could not be seen and...
Editor's note: Dr. Morelli's extended-length letter can be read here.
11/20/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2
From: Jeff Pinsky, DPM
I read the linked article “An insider describes the medical field”, and must say, it opened my eyes. Not so much in what it said; we’ve all had lumps, bumps, and detours in our career paths, and seen how medicine has changed; but in the very many comments left by other readers. I knew the “The American Thinker” was a politically right leaning publication, but hadn’t browsed its pages in years. I laughed at many of the responses, but not the classic comedic laugh; more of the Greek tragedy type of laugh. The volume and tone of the responses to the article gave me a glimmer into what the future holds.
As to how pre-operative patient consultation time has changed, as podiatrists we all spend/spent more time with patients than our MD brethren. As we get farther away from individual practice and more into corporate medicine, we have more demands to generate more revenue with higher patient volume (and lower reimbursement per patient) and faster throughput. Long appointment wait times (6 months+ is not unheard of), high no-show rates, narcotic prescription diversion, and poor patient compliance are all a larger part of our practices than they were in years past. Reminiscing about what used to be is not going to advance podiatry (nor medicine as a whole). We need to take action. Unfortunately, I have no idea what that action may be.
Jeff Pinsky, DPM, Petersburg, VA
11/20/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1
From: Jon Purdy, DPM
I had a similar frustrating experience when I sent myself for my first routine colonoscopy. I was told an exam was necessary and received one from their PA. A little palpation here and there and an order for stool examination. To my protest, I was told the doctor will not do the procedure without it. I complied and received my first bill for a CPT 99204. I questioned the validity of that exam level with the office manager to no avail.
On the day of the procedure, the doctor asked if I was ready and said they would be taking me back. I said what about my results? He looked confused. I told him I was told he would not do the procedure without the stool path and he said “that is not true.” So I underwent my procedure irritated about the entire process thus far. In recover the doctor said, “everything looks great, but there was one spot of inflammation I needed to biopsy.” It was a “Where’s Waldo” game to discern anything in the photo, but I know that extra $350 comes in handy.
So they made some good money on me while I was stuck with unnecessary bills, frustration, and inconvenience. This just verified to me of what is out there, and what I do not do to my patients.
Jon Purdy, DPM, New Iberia, LA
11/19/2024
RESPONSES/COMMENTS (NON-CLINICAL)
From: David Secord, DPM,
My pre-op experience when approaching a surgical case mirrors Dr. Lang’s in that I also try to go into explicit detail with the patient about pre-op, peri-op and post-op expectations. I try to encourage the patient to bring whomever is going to be assisting them during their convalescence, so that they are also in on the whole explanation. I have a volume of graphics which are employed and given to the patient for guidance. I also have bone models in the office to help explain anatomy, physiology, and to give a 3-D representation of the structures involved.
Once everyone is satisfied, I let the patient know that this isn’t the end. A week before the procedure, we have a pre-op visit and we will go over this whole thing again. It is inevitably the case that they have some time to mull things over and have generated new questions. At that pre-op visit, I let them know that they should pick up the pain med and have it with them at the post-anesthesia care unit. That way, I know that they have what they need to stay pain-free as the local wears off and the narcotic can take over. My goal in this is to have the patient know almost enough about what to expect and what is involved that they could do the procedure themselves [hyperbole, obviously.] The patients seem to appreciate the time and effort spent.
David Secord, DPM, McAllen, TX
11/18/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2
From: Bret M. Ribotsky, DPM
I encourage everyone who’s eligible to consider firstnet.com. It runs on the AT&T system, but uses a different band system than every other cell phone. It uses band 14 which gives it higher priority with no throttling, regardless of how crowded the location you are in. It's designed to use for all first responders. When I joined this over a dozen years ago, it required me to have ER responsibility.
And with all this added benefit, it was less expensive even with the standard discount. It surprises me that not more people knew of this. I talked about this in my last year or so of lecturing before my accident.
Bret M. Ribotsky, DPM, Ft. Lauderdale, FL
11/18/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1
RE: My Surgical Experience as a Patient
From: Joel Lang, DPM
I recently had an outpatient surgical procedure under general anesthesia. While the procedure itself went well and I have largely recovered, I feel there are lessons I can share regarding this experience. I was told to show up early for the procedure to complete about eight pages of medical information forms and releases. So, at a time when I was most anxious about the procedure itself, I had lots of forms to complete.
Between the time I was told in the office that the procedure was necessary and the actual arrival at the surgi-center for the procedure, I accumulated several additional questions for the surgeon and the anesthesiologist. Both were very busy with their schedule at that time and had only limited...
Editor's note: Dr. Lang's extended-length letter can be read here.
10/30/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1C
From: Paul Kesselman, DPM
I have to partially disagree with Dr. Tomczak. There is no question that the MD degree may get doors open that another doctorate degree may not. I also know at least 2 MDs who either decided not to pursue residency programs or who quit their surgical residency in midstream to pursue other areas of interest, such as medical IT, etc. This area is growing by the day as physicians with clinical experience and those in medical school see how difficult clinical practice is.
However I know many DPMs who, for one reason or another, pursued work outside the clinical arena in the pharmaceutical industry, orthopedic equipment or orthotics and prosthetics industries, and some even the teaching profession, at one level or another. Other DPMs are working for insurance companies as investigators, others as...
Editor's note: Dr. Kesselman's extended-length letter can be read here.
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