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07/16/2026
RESPONSES/COMMENTS (DME) - PART 1
From: Gary S Smith, DPM
I had a similar issue. My staff made some minor mistake on our re-application. We didn't find out until we were denied DME claims. She had fixed the mistake in time and there were no mistakes. They told us they were "still processing it". This went on for months. It started in May. In September, we contacted PICA because they cover things like this. The lawyer thought it was a big joke and did nothing. All I got was a huge increase in my PICA premiums.
Finally, in January, we contacted our congressman. In about 2 weeks, the ball got rolling and our re-application was approved. They did pay for the denied claims from over the previous year. I imagine they will pay for your claims made after you re-applied but not in between lapses. You can bill the patients.
Gary S Smith, DPM, Bradford, PA
Other messages in this thread:
09/06/2024
RESPONSES/COMMENTS (DME) - PART 1B
From: Paul Kesselman, DPM
There are some exceptions to the requirements for a DME provider's location to be open to the public. Some exceptions include pharmacies which serve long term care facilities, hospitals, physicians who only perform house call services, mail order facilities which serve as fulfillment centers (for surgical dressings) and others.
A physician who treats patients in nursing homes, must (as their colleagues do who only perform house calls) still maintain a business office where they maintain compliance documents. This includes charting, invoicing, billing, inventory etc. In completing the enrollment process, the application does ask questions regarding where records are maintained if not in the location where the services are located. Today, that location may be the cloud, but the laptop you use needs to have a physical address where the cloud is reached and thus even your home address can serve as your business office location. Your business location would need to comply with the Supplier Standards as they apply to a business location and would be subject to an inspection by the enrollment carrier prior to approval of your DME location number (PTAN).
There is a significant amount of more material to review far beyond what can be provided here. I strongly urge you to contact an individual who has expertise in this matter for a thorough review of your specific circumstances.
Paul Kesselman, DPM, Oceanside, NY
09/06/2024
RESPONSES/COMMENTS (DME) - PART 1A
From: Steven Finer, DPM
Yes, it is possible. When I practiced and saw nursing home patients, there were a number of requests for shoes. I had a DME primarily for the office where I had a dedicated room. I merely became a go-between between the MD who wrote the diabetes note, my script for the shoes, and the person who actually filled the order.
I saw it as very time-consuming for the limited amount of time spent, with audits shoe adjustments, and patient complaints. The nursing home was bombarded with outside vendors dispensing shoes of poor quality. In reality, it is possible as you are full time but accept all the hassle. Rules and regulations have become stricter due to fraud.
Steven Finer, DPM, Philadelphia, PA
09/27/2023
RESPONSES/COMMENTS (DME) - PART 1C
From: Joel Morse, DPM, Robert Kornfeld, DPM
I recommend that you send out another letter and explain what the CPT code is that you use and show us a copy of the notes that you have so that we can see what is going on. I think that as long as you use the L 3000 code and you have all of the specifics of what type of an orthotic you dispense and the correct ICD-10 codes, you should be paid much more than $70 an orthotic.
Joel Morse, DPM, Washington, DC
I think what you charge depends on the value you deliver. I charge more than twice your $400 fee. And it is paid in full in cash. I do not accept insurance of any kind for the past 23 years. Here is why - patients are not just paying you for a product, they are paying you for the value they receive from the orthotic. This is what is missing from insurance-dependency. You are providing services that have lasting benefits for your patients in many ways, and there is way more value in that than just charging them for a piece of plastic. I'm sorry, but providing your patients with orthotics for $30 is downright insulting to you. But as I have stated many times, when you say yes to less, that is what you are going to get. As long as you are beholden to an insurance company to get paid, you will continue to be underpaid and exploited.
Robert Kornfeld, DPM, NY, NY
09/27/2023
RESPONSES/COMMENTS (DME) - PART 1 B
From: Donald R. Blum, DPM, JD
Because you have analyzed the cost of prescribing "custom" orthosis and are finding the cost to your practice as being prohibitive, you might consider an alternative. I think you missed other important costs to your practice - the time it takes to explain the purpose of orthosis, the time it takes to make an impression of the feet, the time it takes to fill in the order form, the time it takes to send the impression to the lab, the cost of postage for the lab to return the product to you when completed, and the cost if you need to return the appliance to the lab for any correction.
I suggest you are not making a $39 profit. Consideration could be made to charge the patient for the service just like you might when using a laser for treatment of nail fungus, or when using extra corporeal shockwave therapy, or selling the patient an OTC product or other services you might offer the patient that are not covered by health insurance. The alternatives are to let the patient go to a retail store for this service or continue taking the ownership for this service and lose money on a service for the benefit of your patient.
Donald R. Blum, DPM, JD, Dallas, TX
09/27/2023
RESPONSES/COMMENTS (DME) - PART 1 A
From: Elliot Udell, DPM
The problem with orthotics is not whether insurance covers them. The problem is if the patient's insurance does cover custom orthoses and pays you 120 dollars for a set, which is some cases, is less than the lab fees. The classic case in my practice was when a patient came in requesting custom sports orthotics. He was an avid tennis player. I called the insurance company and was told that he is covered and they would pay me twenty six dollars and fifty cents per foot. I called the patient and explained that I could not afford it. He begged me and told me that he would pay me out-of-pocket for the orthotics. I accepted his offer and even gave him a discount. He was happy with the orthotics. Six months later, I get a call from his wife and the rep from the insurance company. I was told that I was contractually obligated to reimburse him and take the 26 dollars per orthotic and eat the loss.
I've since learned that if the patient does have insurance that pays below lab costs, I either will dispense Powerstep orthotics or send the patient to a company such as Hangar orthotics and let them handle the finances. If the patient does not want to pay me for non-custom orthotics, I will simply refer them to Amazon and let them buy them but I do let the patient know that should it be necessary, I will not adjust an orthotic bought from Amazon or a sporting goods store.
Elliot Udell, DPM, Hicksville, NY
06/01/2023
RESPONSES/COMMENTS (DME) - PART 1B
From: Paul Kesselman, DPM
It was important to provide an additional response to the letter I provided in a recent issue of PM News. I purposely did not expand on the issue of when the NP/PA does the foot exam and prescribes the shoes (as they have the legal right to) and thus is the prescribing entity. This circumstance was purposefully omitted out of an abundance of creating more confusion. But since Dr. White brought this up, I feel compelled now to clear that issue up as well.
Dr. White is correct in that PAs and NPs under Medicare are eligible prescribers for therapeutic shoes and inserts, as well as ordering many other tests and DMEPOS. That is NPs/PAs can both prescribe shoes and inserts working incident to (under direct supervision with the MD/DO in the office) or under general supervision (when the MD/DO is not in the office but...
Editor's note: Dr. Kesselman's extended-length letter can be read here.
06/01/2023
RESPONSES/COMMENTS (DME) - PART 1A
From: Terry Reed, C Ped
Currently, CMS is doing massive audits on diabetic shoes and are very picky about what they allow. An NP may conduct the exam but it has to be signed by the MD or DO overseeing the patient's diabetic plan of service, and not just signed. There must be a statement such as, "I agree with the above findings" or CMS will reject it.
Also, the auditors will claim that the MD or DO is not truly overseeing the patient if they have not personally seen the patient in the past six months. In other words, people in rural areas who go to a clinic manned by an NP who has their practice overseen by an MD or DO are flat out of luck because they never actually see that doctor.
Terry Reed, CPed, Wynne, AR
05/31/2023
RESPONSES/COMMENTS (DME) - PART 1B
From: Josh White DPM, C.Ped
PAs and NPs are permitted to do foot exams, documenting qualifying risk factors for therapeutic shoes and to complete a Statement of Therapeutic Necessity. Medicare still requires an MD/DO to be the Certifying Physician. It is okay if they provide "general supervision (versus direct)" of the NP/PA.
It is still necessary for the certifying physician to co-sign the certifying statement and foot exam. Often, this is a challenge to execute. It is NOT okay to get the NP/PA signatures without a MD/DO co-signing it.
Josh White DPM, C.Ped
05/31/2023
RESPONSES/COMMENTS (DME) - PART 1A
From: Paul Kesselman, DPM
CMS attempts to facilitate access for therapeutic shoes to patients who only see PAs or an NPs has been a flop. It also has confused the auditors at every level, created a larger paperwork trail. Even my fellow DME council members continue to flood my phone and email box just having reviewed this issue during a council meeting. So to try to give a straight answer covering every scenario in this format would be nearly impossible. This is what a PA can do:
If you are the supplier and prescriber: They (the PA) can perform a systems exam, sign the supervising physician statement, and attest agreement with your notes. However, every single one of those documents must be co-signed and dated by the...
Editor's note: Dr. Kesselman's extended-length letter can be read here.
05/17/2021
RESPONSES/COMMENTS (DME) - PART 1B
From: Josh White, DPM
As the director of OrthoFeet’s medical division, I can share that we have not had a price increase on diabetic shoes nor pre-fabricated/custom inserts in over a year. While the cost of shipping containers from China has increased substantially, we have not passed this on. The cost of FedEx, UPS shipping has increased but these charges have also not been passed on as we negotiated better volume discounts.
OrthoFeet has NO backorder issues; we receive thousands of shoes a day from China. The biggest supply chain problem regarding diabetic shoes is the difficulty DPMs encounter in obtaining certification that the patient is under the care of an MD/DO for their diabetes and have been to this physician no more than 6 months prior to being fit with shoes. The APMA and the new LEAP Alliance have been working for years to remove this obstacle. With approximately 50% recurrence of foot wounds within a year of healing, the need for patients to be expertly fit with quality shoes has never been greater.
My suggestion is for practices to assign the task of documentation procurement to someone and incentivize them to do the necessary follow-up to obtain the required forms. Make sure your patients understand the importance of shoes in enabling their mobility and independence and that the MD/DO understands their responsibility in the team approach to care. Once patients are fit, the process should be repeated annually. With over $225 profit possible per pair of shoes and inserts, there is plenty of opportunity for everyone involved to benefit.
Josh White, DPM, CPed, VP, OrthoFeet
05/17/2021
RESPONSES/COMMENTS (DME) - PART 1A
From: Lawrence Rubin, DPM
I understand that optometrists are also having a supply chain issue getting timely delivery of custom eyeglass frames and lenses. It appears that the worldwide impact of COVID-19 is resulting in delays due to fewer employees on the production end in the factories, and also fewer workers on the job in the other links of the supply chain.
Lawrence Rubin, DPM, Las Vegas, NV
01/29/2021
RESPONSES/COMMENTS (DME) - PART 1B
From: Jon Purdy, DPM
A few years back, after about 30 denials for payment on shoes and inserts, I gave up. I sent all to the ALJ level and waited three years to have the hearings. My documentation is in perfect order, and my patient criteria is without question. In the vast majority of cases, they were approved and a couple of judges apologized to me for the hassle. I did have one judge recently who seemed determined to deny my case. At the end, I was explaining the terms to her which she apparently did not understand. It was subsequently approved.
This is an obvious trend to keep a defined benefit in place while creating barriers to delivery of service in hopes it becomes too cumbersome for physicians to utilize and bill. They win, the patient loses. Physicians alone cannot win all battles without the public becoming involved in the fight over ever increasing deductibles and diminishing services. Medicare today resembles nothing of what the original legislation promised, which is no surprise.
Jon Purdy, DPM, New Iberia, LA
01/29/2021
RESPONSES/COMMENTS (DME) - PART 1A
From: Billy Dabdoub, DPM
I want to thank my colleagues for raising this important issue at the beginning of this congressional session. I’ll start by recommending that they can begin to educate themselves on this and other issues impacting our profession by becoming members of their state component and members of APMA. Our professional associations are our voice in our state and national capitals, and they keep us informed about what’s happening to our profession and the threats which we must overcome.
APMA has been actively working to address the problems with the Medicare Therapeutic Shoe Program for patients with diabetes for more than a decade. Several resolutions have been passed over the years by the APMA House of Delegates to address this issue and to reinforce the importance and priority that the profession places on...
Editor's note: Dr. Dabdoub's extended-length letter can be read here.
01/28/2021
RESPONSES/COMMENTS (DME) - PART 1B
From: Paul Kesselman, DPM
I have read the postings regarding the time for podiatry to do "something" about DM shoe requirements. Unfortunately, the "something" has been equated to actually succeeding. And while unfair, that assumption is readily understandable to me as both a provider of therapeutic shoes and chair of APMA's DME Workgroup. APMA and other organizations have had a litany of meetings with the DME MAC contractors regarding this matter. I actually attended my first meeting with the then SADMERC (now PDAC) well over 15 years ago, and I have attended many more since with other DME MACs on this issue.
At one point, a former DME MAC Carrier Medical Director joined me and APMA officials to speak to the DME MAC Carrier medical directors, asking for relief for suppliers. Unfortunately to no avail. Recently, NP/PAs have been given...
Editor's note: Dr. Kesselman's extended-length letter can be read here.
01/28/2021
RESPONSES/COMMENTS (DME) - PART 1A
From: Steven Finer, DPM
You are paying for the sins of others. When I was in practice, patients would come in with shoes from suspect private stores where the shoes were obviously not custom-molded. The inserts came right off the shelf with no corrections for lesions, etc. I repeatedly would tell the patient to go back and complain. One showed me a pair where some charlatan placed a one cent rubber pad inside and charged him $80.
I had a family of patients that would brag to me as to the number of shoes they could get. Read old OIG reports about the abuse with braces, scooters, TENS units, and power chairs. As an ethical practitioner, you are being inundated with paperwork for saving people's feet. Blame the system. The free lunch is never free.
Steven Finer, DPM, Philadelphia, PA
01/27/2021
RESPONSES/COMMENTS (DME) - PART 1B
From: Jeffrey Kass, DPM
I must compliment Barry Block, DPM, JD (editor of this forum) for allowing colleagues to express opinions here. It is becoming a little bothersome to continuously read problems the profession faces at this stage of the “profession”. Podiatry has evolved. Our colleagues have advanced this profession by leaps and bounds. Drs. Sokoloff and Marcus eloquently write about their frustrations with volunteering for administering Covid shots and the absurdity of the rules and regulations of the diabetic shoe program. I agree with them both as I’m sure the overwhelming majority of podiatrists do.
I’m curious what the APMA’s position is on these topics and why it is so difficult to straighten the BS out? Multiple drug companies figured out in “warp speed” how to create a vaccine in record time but podiatric leadership can’t figure out a way for a podiatrist to dispense a diabetic shoe to a patient missing multiple toes without writing an encyclopedia, asking an MD to sign off on it, and then having the money taken back anyway for not including an Rx even though he was the prescribing doctor.
I encourage those who have ideas how to change some of the dilemmas the profession faces to write in with them. Whether that means having every diabetic patient sign a petition or what not. I mean people - we really ought to put some of these issues to rest already.
Jeffrey Kass, DPM, Forest Hills, NY
01/27/2021
RESPONSES/COMMENTS (DME) - PART 1A
From: Daniel Jones, DPM
I remember when I was in school. There was 'Vision 2015'. It essentially stated that the goal of podiatry was to have parity with MDs and DOs by 2015. Yet here we are, some 6 years later, still seen as second class physicians, or "allied healthcare providers". Even with the excellent work of the APMA, a podiatrist serving in Congress, and mandatory 3-year residencies (the same as PCPs nationwide), we still have to have a 'real doctor' sign off on our patients. Who knows our patients’ feet better than us? Who sees our diabetic patients more than us?
The point is this: We should be able to sign for the shoes ourselves. My staff and I spend countless hours explaining to our patients that the NP and PA they see for their primary care doesn't 'count' in getting shoes signed for. This also creates a potential rift between podiatrists and NPs and PAs, who see us sending patients they referred to us to another provider for this visit. By signing for ourselves, it eliminates barriers to diabetic ulcer prevention and lets our patients see their PCPs without burdening the system with unnecessary MD/DO foot checks.
For better or worse, there will be political changes to the practice of medicine. Likely, one of these multi-thousand page bills will be signed into law. Can we have just one of those pages give parity to DPMs? Title XIX has hindered us long enough. It's time for DPMs to take their seat at the table with MDs and DOs.
Daniel Jones, DPM, Casper, WY
07/28/2020
RESPONSES/COMMENTS (DME) - PART 1B
From: John Chisholm, DPM
I highly recommend Rybo Medical in Lake Forest, CA. Great devices great prices, great service. I have no relationship with Rybo Medical except as a loyal customer for many years.
John Chisholm, DPM, Chula Vista, CA
07/28/2020
RESPONSES/COMMENTS (DME) - PART 1A
From: Doug Richie, DPM, Brad Katzman, DPM
The Richie Brace family of lab distributors offer a gauntlet AFO with the patented Arch Suspender: Also, the Richie Brace labs offer the California AFO which is a unique gauntlet brace incorporating the Arch Suspender without any laces.
Doug Richie, DPM, Seal Beach, CA
Check out Biostep. They are located in Panorama City, California. They make excellent orthotics and custom braces at extremely reasonable pricing with excellent products and service.
Brad Katzman, DPM, Chino Hills, CA
04/03/2018
RESPONSES/COMMENTS (DME) - PART 1B
From: Joseph Borreggine, DPM
It comes directly from CMS and fully explains the fee amount and reasons why it needs to be paid.
Joseph Borreggine, DPM, Chalreston, IL
04/03/2018
RESPONSES/COMMENTS (DME) - PART 1A
From: Paul Kesselman, DPM
CMS instituted a re-validation fee for DMEPOS providers five or more years ago. Since this re-validation is only for a period of three years, I am curious how you may have re-validated without having to pay the piper when you last re-validated. CMS requires validation payment(s) from certain types of providers, which is why as physicians under Medicare we don't pay. However, the NSC which enrolls suppliers doesn't have a special category entitled "Physician Suppliers". DPMs, MDs, or DOs are considered suppliers and are offered no special exemption. Thus, you must pay the triennial payment.
The NSC will not even initiate the re-validation process until that fee is paid.
Paul Kesselman, DPM, Woodside, NY
10/27/2016
RESPONSES/COMMENTS (DME) - PART 1B
From: Martin V. Sloan, MS, DPM
With my prior billing company, I dispensed and billed for the boot at the time of surgery, place of service "hospital or surgery center". With my current billing company, eClinical Works, I dispense the boot from the office prior to surgery and bill for it separately. EClinicalworks argues that we cannot bill for DME at the "hospital place of service" because that is not our registered locale for dispensing of DME. I include a letter of medical necessity within the EMR.
Martin V. Sloan, MS, DPM, Abilene, TX
10/27/2016
RESPONSES/COMMENTS (DME) - PART 1A
From: Paul Kesselman, DPM
Surgical shoes are a non-issue and are a cash product which is not covered by Medicare and almost every third-party payer. Therefore, there is absolutely no reason why you could not dispense this item to your patient prior to surgery. The profit on these is slim, with most providers not charging more than $30 and the lowest cost I've seen being about $5, only usually leaving at most a $25 profit.
When it comes to CAM walkers, however, that is entirely another story. One must also divide this discussion into non-Medicare and Medicare. Most third-party non-Medicare payers will only pay for such an item when there is medical necessity; however, because each payer operates under its own rules, one should...
Editor's note: Dr. Kesselman's extended-length letter can be read here.
03/02/2016
RESPONSES/COMMENTS (DME) - PART 1B
From: Daniel Chaskin, DPM
If a DPM practices in an area considered by CMS as a "Health Manpower Shortage Area", then that podiatrist may be defined as the "certifying physician" and perform the required DCE.
What about a homebound patient who can only find a NP to perform house calls, and what if MDs refuse to come to the home? Why can't CMS expand its definition of "Health Manpower Shortage Area" to include any homebound patient's address where it is difficult to find an MD willing to perform a house call? Why can't the podiatrist then be defined as the certifying physician?
Daniel Chaskin, DPM, Ridgewood, NY
03/02/2016
RESPONSES/COMMENTS (DME) - PART 1A
From: Paul Kesselman, DPM
While I was not on this call due to a scheduling conflict, I was told that the meeting with NGS went very well. This meeting was arranged for by APMA and open to all. The presenters of NGS were members of the Provider Outreach and Education (POE) team, not auditors or a Carrier Medical Director (CMD).
Prior to this call, one week earlier, a conference call took place with Dr. Hoover (Region C CMD) and supervisory auditors from CGS, along with some APMA staff and a few others selected by APMA. This call was initiated by the Georgia Carrier Advisory Committee rep, Dr. Len La Russa who himself had 12 of 16 claims slated to go to the ALJ pulled and ordered paid by the supervisor of the auditing staff at CGS. She had researched these claims and found...
Editor's note: Dr. Kesselman's extended-length letter can be read here.
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