04/18/2025 Allen M. Jacobs, DPM
OIG and Potential Abuse by Medicare Part C Plans and Lower Extremity Revascularization Procedures (Paul Kesselman, DPM)
Dr. Kesselman has offered a concern and has
advised precaution in referrals to interventional
radiologists, interventional cardiologists, and
vascular surgeons. My experience over the last 2
years would support his warning. I have had the
occasion to review multiple litigation scenarios
in which a podiatrist has been named in a suit,
rightfully or wrongly, for alleged inappropriate
referral to interventionalists.
In some circumstances, podiatrists have entered
into co-investment agreements with free-standing
cath labs, somewhat similar in structure to that
typically constructed with surgical centers. At
least one national chain of such cath labs,
offering stock and investment opportunity for the
podiatrist, has come under federal investigation.
Lawyers are aware that the podiatrist stands to
benefit financially with increased use if the cath
lab facility. Typically, the podiatrist is
encouraged to refer the patient for arterial or
venous studies, following which a decision
regarding the need for invasive therapies is
determined.
In one case, the patient was referred with no
documented compelling evidence of PAD.
Nevertheless, the interventionalist determined
that a percutaneous procedure was necessary, and
unfortunately the patient sustained a serious
injury due to complications in performing the
procedure. The podiatrist was sued on the basis
the he had known or should have known there was no
evidence of PAD, and a series of similar referrals
became evident. The financial benefit to the
podiatrist acting in this manner became all too
evident.
Increasingly, I have evaluated cases in which a
podiatrist is accused to making an inappropriate
referral to interventional radiology or
interventional cardiology rather than vascular
surgery. Although not common, there is some
animosity between some vascular surgeons against
interventional cardiology and interventional
radiology with regard to peripheral work. The
situation reminds me of the occasional orthopedic
surgeon who is always critical of any surgery
performed by a podiatrist. This critique is
particularly evident with interventional
radiology, with the argument that PAD does not
exist in a vacuum, and generally more than a stent
or angioplasty is required to manage the patient,
and that interventional radiologists lack the
education and skill to totally manage the patients
need (eg: medications for PAD or concurrent
comorbidities).
With reference to interventional cardiology, some
vascular surgeons argue that patients are
subjected to percutaneous procedures when an open
procedure, eg bypass, was indicated. I have
evaluated several cases in which the podiatrist
was sued for not referring to vascular surgery in
preference to an interventionalist. You may not
agree, but as they say "it is what it is".
Radiologists, cardiologists, and vascular surgeons
differ in their knowledge, training, experience,
and capabilities. Your obligation on referral is
first and foremost to protect the patient. You
should have a reasonable understanding of the
competency of any health care provider to whom you
refer, including those for management of PAD.
Finally, be observant in following patients
following percutaneous or open vascular
procedures. The argument that "it's not my job"
sound uncaring to a jury. Stents can fracture, re-
stenosis can occur, embolization can occur, any
number of complications may present following
vascular procedures. Sudden changes in Rutherford
status, worsening of a wound, increasing signs of
ischemia, should be noted and the patient referred
back to the vascular surgeon or intervetionalist.
Once again, I have reviewed lost leg cases in
which the allegation against the podiatrist has
been failure to react to changing clinical signs
and symptoms which were in hindsight possibly
associated with vascular procedure failure or
complication.
There is a reason that a closer association has
developed over the years between vascular
surgeons, interventional cardiologists, and
podiatrists. Podiatry represents a significant
potential referral source to these specialists.
Increasingly, we lecture at their meeting and they
at ours. We have a mutual interest: limb salvage
and/or prevention of serious complications from
arterial and venous and lymphatic disorders.
However, with that comes an increasing
responsibility to our patients that we must, as
Dr. Kesselman intimated, seriously address.
Allen M. Jacobs, DPM, St. Louis, MO
