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11/11/2025
RESPONSES/COMMENTS (MEDICARE)
RE: Medicare Part D
From: Lloyd Smith, DPM
The changes to Medicare and the implementation of Part D were promulgated under the George Bush administration. Part D, in particular, benefits insurers and pharma. The limits on Part B are shared by all providers and were designed to prevent a Medicare bankruptcy.
The $2,000 cap for Part D is a step in the right direction. Allowing Medicare to negotiate drug prices is long overdue. Only Congress can alter the Part B formula.
Lloyd Smith, DPM, Newton, MA
Other messages in this thread:
11/12/2025
RESPONSES/COMMENTS (MEDICARE) - PART 1
From: George Jacobson, DPM
By lowering the out-of-pocket costs, you perpetually now have a higher part D premium to make up for it, whether you have cheaper generics or no medications. People went from low or no premium to $100 per month (Aetna/CVS) to pay for the lower cap. My part D is now higher than my part B supplement. There is still one part D plan in my area with $0 premium which I’ll change to, but they’ll probably catch on next year to increase their cost too.
George Jacobson, DPM, Hollywood, FL
11/12/2025
RESPONSES/COMMENTS (MEDICARE) - PART 2
From: Paul Kesselman, DPM
While CMS has announced the “Final Rule” for the Physician’s Fee Schedule, things are far from finalized from CMS for 2026. There are many more final rules which CMS has yet to release. These no doubt will also affect all physicians, either directly or indirectly. They include the Medicare Outpatient Prospective Payment System and home health final rules as well as those impacting DME suppliers. Late October and early November are always a bumpy road for these final rules.
As for Dr. Smith’s comments on Medicare Part D, the insurance companies are constantly changing their formularies and in so far as I understand, they are the ones who decide which drugs are to be covered, not CMS. Thus, the variability in drug formularies between companies changes from year to year. Some Part D drugs move to Part B which means the physician administering the medication may now bill Medicare for it. On the other hand, some drugs move from the Part B arena to Part D, in which case the patient’s pharmaceutical plans cover the medications.
With the myriads of medications and pharmaceutical plans and coverages, it behooves one to use an insurance broker who can work off a survey of your medications and provide you with choices from which to pick. Some plans have a high deductible and high co-pay but low premiums. Others have higher monthly premiums but lower or no deductible and lower co-pays. Which medications and whether they are generic vs. brand name and which tier they are in are all basic questions to be answered by someone knowledgeable about Part D Medicare. It is incumbent to work with a broker who can provide you with a detailed prospective for you to make an intelligent decision based on what is best for you and NOT what is best for the broker’s commission.
Paul Kesselman, DPM, Oceanside, NY
09/17/2025
RESPONSES/COMMENTS (MEDICARE)
RE: MMSEA 111
From: Paul Kesselman, DPM
CMS in its infinite wisdom has announced a new acronym MMSEA 111, Medicare, Medicaid, Schip, Extension Act of 2007, Section 111. This new policy should alert you that you must report incidents where you can identify payments which should not have been paid by Medicare but rather by another carrier. That is Medicare should have been the Secondary Carrier as the patient may have been covered by another entity.
While this is not really a new policy, the heavy handedness and penalties soon to go into effect are really incredible. One example, is that effective January 1, 2026, CMS will be conducting random audits going back to the first date of...
Editor's note: Dr. Kesselman's extended-length letter can be read here.
07/07/2025
RESPONSES/COMMENTS (MEDICARE)
RE: Upcoming Medicare Issues
From: Paul Kesselman, DPM
1) Prior Authorization. On Jan 1, 2026 Medicare is implementing a pilot prior authorization program in several states for several procedures including cellular tissue products.
2) Common Electronic Data Interchange. For those submitting DME claims electronically, the time to revalidate your CEDI trading partner number starts on July 1 and runs through December. It takes only a few minutes. If you need assistance with this, your EHR should be able to assist you.
3) Re-validation. Medicare is contemplating changing the DME enrollment re-validation from triennial to annual. There were no updates on the fee, so one can assume for now that the fee would still be paid on a triennial basis, while the revalidation would be annual. I have been told that this will only affect those who require facility accreditation (DPMs do not). Facility accreditation fees are also going up.
Paul Kesselman, DPM, Oceanside, NY
06/19/2025
RESPONSES/COMMENTS (MEDICARE)
RE: Medicare Part C Risk Adjustment Audits
From: Paul Kesselman, DPM
Several recent announcements have made it clear that the Feds finally are making a concerted effort when it comes to Risk Adjustment Fraud. That is the Feds have announced that every single Medicare Plan C plan will be audited for Risk Adjustment Data Evaluation (RADV). Many healthcare law firms have announced webinars on what to expect with these investigations. While these are not audits of your practice, these investigations may nevertheless cause some increase in the number of requests for information from practices, where the investigators compare our charts and claims to the conclusions reached by the MCR Part C carrier.
While these may be burdensome, if they prove what many of us believe, that the MCR Part C plans are committing fraud, then that increased burden may just be worth it. If the plans are guilty, as most of us believe, then the punishment should be not only civil, but criminal charges need to be brought against the officials of the companies who perpetuate these crimes. The loss has been staggering to the Medicare Trust fund and the bleeding needs to stop now! Time will only tell whether the OIG and this task force are a paper tiger or the real deal.
Paul Kesselman, DPM, Oceanside, NY
01/13/2025
RESPONSES/COMMENTS (MEDICARE)
From: Elliot Udell, DPM
When Medicare and other insurance companies begin to cut fees paid to physicians, we might feel the pain, but the ones most adversely affected are our patients. Remember, we are not only doctors but also patients.
Except for the subset of the patient population that are also caregivers, the average "Tom, Dick or Harry" going for medical care might not realize why many physicians are spending less time with them and are often ordering more high-end tests from labs, hospitals, and radiological centers that are affiliated in some way with the hospital or corporation that now employs the physicians.
The more Medicare and other insurance companies continue to cut back, the problem of America providing optimum healthcare to patients will be less and less.
Elliot Udell, DPM, Hicksville, NY
01/11/2025
RESPONSES/COMMENTS (MEDICARE)
From: Judd Davis, DPM
Dr. Kass, I feel your frustration. Every year, there is talk of the annual Medicare cut in Fee For Service payments to providers, and every year there is this last minute push by AMA, APMA, etc. to avert it. I didn't pay much attention to it this year and assumed it was averted, but it was not. I just compared the 2024 vs. 2025 Medicare fee schedules on the Novitas website, and low and behold all of the CPT codes I searched are paying from 2.2-4.6% less this year than last (a web search reveals it’s an average of a 2.8% cut). This doesn't even include the 2% sequestration. So in 2025, we are taking a 4.2-6.6% pay cut on our Medicare payments thanks to our legislators. Do you think they would take such a cut in their pay, HECK NO! Since most of the commercial payers, Tricare, etc. base their payments off the Medicare fee schedule, it will be across the board, and the CEOs of those companies can laugh all the way to the bank as they continue to increase their premiums, pay doctors less, and increase profit margins.
Rest assured your landlord, suppliers, and employees will not be interested in taking a similar pay cut to help you get by, and will instead expect or demand a yearly increase/raise. The topic of why applicants to podiatry schools are diminishing comes up on this forum regularly. Well, here is one huge reason! Since podiatry is at the bottom of the barrel when it comes to income compared to other medical specialties, why would someone want to invest such time, money, and energy to become a limited scope DPM, with a continually declining revenue/income facing them, compliments of our government? If only we could all go concierge and drop insurance entirely or unionize to change things, but it is not likely to happen.
Judd Davis, DPM, Colorado Springs, CO
01/09/2025
RESPONSES/COMMENTS (MEDICARE)
RE: Medicare and Sequestration
From: Jeffrey Kass, DPM
We are still in sequestration. To my knowledge, this will continue through 2032. This Medicare sequestration is essentially a backstop because lawmakers could not reach an agreement on how to meet the maximum deficit amount for each fiscal year. If doctors have to incur the pain of their salary being reduced year after year, how do these lawmakers give themselves raises? And why aren't they mandated to share in the 2% reductions in their salaries? After all, they are the ones who can't balance the budget, not the doctors.
Jeffrey Kass, DPM, Forest Hills, NY
12/11/2024
RESPONSES/COMMENTS (MEDICARE)
From: Robert Kornfeld, DPM
Dr. Freireich poignantly points out that "No other profession would put up with this year after year." And he is right. This is the point that I have been trying to get across for decades now. There is no profession that I know of that is as highly regulated and consistently exploited and abused as doctors. Every one of you who participates with insurance year after year, either by running a practice that depends on insurance reimbursements or are employed by PE, where insurance is still the method of reimbursement for the corporation are actually, perhaps unwittingly, feeding the monster.
As long as you "employ" the insurance companies to run things, they will continue to steal from you. And since they know you don't do anything about it, they steal more and more every...
Editor's note: Dr. Kornfeld's extended-length letter can be read here.
12/10/2024
RESPONSES/COMMENTS (MEDICARE)
From: Ron Freireich, DPM
WOW! a 1.8% increase
1.8%-2.6% (current inflation rate) = We still lose
And please don't say it's better than a 2.8% pay cut. Either way, physicians are STILL on the losing end. No other profession would put up with this year after year.
Ron Freireich, DPM, Cleveland, OH
12/09/2024
RESPONSES/COMMENTS (MEDICARE)
RE: URGENT - Contact Your Representative About H.R. 10073
From: Mark Ray, DPM
Tell your Representative to co-sponsor the Medicare Patient Access and Practice Stabilization Act (H.R. 10073)!
"Recently, Reps. Greg Murphy, MD (R-NC) and Jimmy Panetta (D-CA) introduced the "Medicare Patient Access and Practice Stabilization Act" (H.R. 10073). This bipartisan legislation seeks to eliminate the looming 2.8% payment cut and provide a 1.8% payment update in 2025, an actual payment increase equal to one half the Medicare Economic Index (MEI), helping to stabilize physician practices and protecting patients' access to care.
Time is running out – there are precious few legislative days left before the end of the year with Congress expected to conduct a "lame duck" session after the elections. This will be the last opportunity for Congress to pass H.R. 10073 as part of the final year-end package."
Source: Physicians Grassroots Network
Mark Ray, DPM, Ligonier, PA
09/24/2021
RESPONSES/COMMENTS (MEDICARE)
RE: Improper Billing Practices of MCR Advantage Plans
From: Paul Kesselman, DPM
Recently, the OIG conducted an investigation on improper billing practices of MCR Advantage Plans. Being aware of what these companies are doing and how they continue to rip off the taxpayers is something we need to be keenly aware of. These companies can only make a profit if: 1) They don't provide care; 2) They undervalue and underpay our services 3) They engineer a scheme by which to obtain more money from CMS (that's us the taxpayer). They have accomplished all three.
So while it is easy for me as a non-clinical practitioner to pontificate not to do business with them, you can make a difference by making it more difficult for them to deny care (with and w/o your patient as they have a degree of responsibility here as well). Take stock of what you are worth and does it really address your worth? Only you can answer that question.
Also be keenly aware of number 3 and do your best to make it as difficult for the named carriers in this report to use your data (that's right it is your data) correctly. I'm not exactly sure how that can be accomplished, but perhaps it starts by requesting the carrier provide your data back to you, so that you can ensure it is correct. The report can be found here.
Paul Kesselman, DPM, Oceanside, NY
12/31/2013
RESPONSES/COMMENTS (MEDICARE)
RE: Locating One's PECOS Number (Chuck Ross, DPM)
From: Paul Kesselman, DPM
Dr. Ross is likely referring to the NPI Number and password. If you can't find your password, you should call the NPI enumerator 1-800-465-3203 ( NPI Toll-Free) or email customerservice@npienumerator.com.
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