Attn: TFPs

[Carbon13]

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Is it legal to only accept self pay for routine nail care in the private practice setting ?

Regardless of insurance type or coverage, qualifying modifiers, diabetes, laziness, etc, etc....


Reasoning:
No matter how much I discourage routine nail care, I will have endless patients requesting this service.

1. I don't consider this to be worth the time and hassle. It was nice to fill the schedule a few years ago. I don't want to have a team of MA's performing nail care for me either.

2. I find my billing team and office staff spending just as much time chasing down payments from odd ball primary and secondary insurances and Medicare replacement plans in hopes of getting paid a few bucks for this service. They are chasing 45$ instead of 450$.

3. Yeah, I get a few random nail care patients that lead to TNC, MTH excision & other higher paying CPTs. However, majority of those patients I find will locate me directly for those problems as new patients. So, I don't appreciate too much added value in keeping RNC around.

4. I get several patients that "semi" qualify for routine nail care and the ones that don't will argue indefinitely that the previous TFP in California or Kansas or wherever saw them every so many weeks and they never had to pay. Or, "my insurance says I get my nails done 3x per year no matter what" (I absolutely don't like a patient telling me what should or should not be covered).

5. In the recent past I have heard a few stories about pods getting audited by insurance over routine nail codes. I would absolutely have a stroke if I got audited for this reason and had to pay any fines. I would probably submit my CV to Buc-ee's or move to Greenland at that time.

Bottom line: Can I accept cash only or is my only option to punt them to another doctor at initial request ?



Outside example:
I have derm & plastic friends that perform blepharoplasty as self pay only option.
I was told that if you have medical documentation that 30% of vision is obstructed that this is insurance covered procedure.
However, these doctors simply tell even the low vision patients that if they want the service possibly covered by insurance then to go elsewhere.

 

[Adam Smasher]

The way my eyebrows perked up when I saw this subject heading...

1. If you can fill your schedule with non-RFC, in other words, actually medically necessary care, congratulations, you are living my dream. Tell people "I'm not that kind of doctor. No, I don't know who is, either." If you want to charge cash for nail care on patients who have a qualifying diagnosis like neuropathy or PAD, I'm pretty sure Medicare legally requires you to submit an insurance claim. If you don't want to trim nails, just stop doing it. If you wish to continue...

2. Make a list of which payers are repeat offenders. When patients follow up with you, let them know their insurance is shafting you and make them sign an advanced beneficiary notice and submit the claim with a GA modifier. "I'm sorry, your insurance has been giving me some trouble. I'll submit this and they might pay, but they're making me have you sign this form." Act like the insurance company is the bad guy, not you, not the patient.

3. Nail care patients generate plenty of referrals...for more nail care.

4. Again have your patients sign an ABN, Everyone drops their attitude when they see the abn.

5. I think if you uniformly bill all nail care as 11721, then your audit risk is much higher. You have to mix up your codes, some people are 11720+11719, and some people are just 11719. This is the kind of lilliputian hair-splitting I absolutely detest, but it is an integral component of any TFP practice.

If you choose to stop trimming toenails, find out about a foot care nurse in the area and hand out that person's business card to your patients. Nail care is not a life-sustaining treatment and you are not obligated to find someone who will do it for them and accepts their insurance.

 

[Mia McBhul]

If you can fill your schedule with non-RFC, in other words, actually medically necessary care, congratulations, you are living my dream.

my sentiments exactly...

 

[Retrograde_Nail]

I'm hospital based. I have an NP who does the routine foot care that qualifies. We still don't see non qualified RFC unless they sign an ABN.

The ABN has a 95% kill rate in my practice. Once they see the prices they refuse to sign and leave. No fights or screaming.

I have my nurses screen these routine foot care patients before we see them and call them most of the time. If they have no qualifiers then we tell them they need to sign the ABN. This is done over the phone. Once they hear the prices they just cancel their appointment.

 

[heybrother]

I think its safer to simply say "I'm not doing any RFC/HRFC" then it is to tell people - "regardless of if you are covered or not I only perform this service as a self-pay procedure". Awhile back I was in a casual conversation with people who were asking "why can't I do like Neal Blitz and just tell every bunion its $2,000 up front". The answer to this is your contracts with insurance governs what you can charge for covered services. The connection is slightly tenuous but consider the following - "I can't do your [bunion/nail care]. While its technically covered by insurance we have to much issue with [liability / collecting payment / doesn't pay enough / whatever your reason." Perhaps slightly tenuous and more complicated, but our contracts essentially say covered services fall under the contractual terms. The contract governs bunions just like it governs nail cutting.

Options
1. Stop performing all "nail callus services". The most definitive option. "I'm sorry, I don't offer those services anymore". But other doc did them. "I'm sorry, you are free to seek them out from another doctor".
2. Drop all of the odd ball or uncommon insurances that you are having problems with. I have a contract with an insurance that is supposed to pay 125/150/175% of Medicare for E&M/Rad/CPT. The problem is the claims just never get paid and we end up having to pursue payment from the patients. The insurance never even responds even when I write to the rep who writes back all nice saying "I don't know what's happening".
3. Or - continue to perform the services for covered people BUT strict AF. For example, the B criteria say "absent pulse". They don't say non-palpable. A dopplered pulse is not absent. The simple truth is most non-palpables are still present with doppler. And then massively increase the ABN uncovered price. This is still less clean than option 1.

Is there a price where cutting nails/calluses would not bother you if the patient paid cash for it? I'm always curious what people's number is. Some of the numbers from my competitors are shockingly low - like $50-70. That's less than any sort of office visit, less than Medicare, less than even insurance pays.

 

[Bluecollarmed]

My hospital also owns a separate clinic of (not sure really, MAs? CNA?) who do nail care and calluses for cash.. $35. Patient's will still try to side step that because they want insurance to cover it. No one gets madder than a patient who "can't reach their nails" has been told insurance pays for that and then you tell them to kick rocks. Real question is how are you guys billing your warts if you're debriding in clinic and then do OTC/home adapalene or the like? Idk if billers altered things but I had a few get denied because it was falling under the same requirements as calluses.

 

[DYK343]

Only accept trainwrecks for nail care.
Patients that actually need it.
Not patients that want it.
I am strict. Diabetes WITH neuropathy. If that diagnosis is not sent they are denied.
Trainwrecks 80-90% of the time have something wrong beyond just nails. 11721 alone is not worth it. Cant keep the lights on with that diagnosis.
99213 + 11721 is about 1.8 wRVU. Trainwrecks always have a complaint/issue justifying the 99213.
5-6 of these an hour. Its a good payday.
I only do nails 1/2 day a week but it really is my best paying day of the week.
I do not accept Q modifiers. Not worth it. Thats a bad business decision - at least on wRVU model.

 

[Adam Smasher]

Is there a price where cutting nails/calluses would not bother you if the patient paid cash for it? I'm always curious what people's number is. Some of the numbers from my competitors are shockingly low - like $50-70.

My partner did a fair bit of "Cash for keratin," and since he retired we raised our prices from $57 to $60. You would not believe the outrage my secretaries faced. My Google reviews have taken a nose dive but at least I'm offloading these pts to the poor sap in the next town.

Which brings me back to my point above. At a certain level, it has to stop being about the money. If a patient says to you, "I have a sink full of dishes at home, can you wash them for me? I'll give you $600." Are you going to take that offer?

For me, personally, I don't have the luxury of turning this work away. If I stopped nails, all I would have is empty space on my schedule. Yep we need more schools alright.

What I don't get is some of you hospital employed folk who are busy doing actual medical care for people with real problems saying "I trim nails only under XYZ circumstances" when you could just tell these pts to F off. Tell your overlords you're a busy doctor and nailcare diverts your skill and attention from actual patients who rightfully deserve your care. Why bother quoting an FU price when you can just say FU.

Only accept trainwrecks for nail care.
Patients that actually need it.
Not patients that want it.

All nails need to be trimmed the same way all teeth need to be brushed and all butts need to be wiped. I'm being a broken record here, but in a sane universe, nail care is not considered a medical treatment under any circumstances and anyone can go to a licensed nail tech for the same price as a supercuts haircut.

However in the timeline we occupy, nailcare is free under a specific set of circumstances that can only be determined by a doctor with 7 years of training and these findings need to be carefully documented each visit.

 

[Retrograde_Nail]

My partner did a fair bit of "Cash for keratin," and since he retired we raised our prices from $57 to $60. You would not believe the outrage my secretaries faced. My Google reviews have taken a nose dive but at least I'm offloading these pts to the poor sap in the next town.

Which brings me back to my point above. At a certain level, it has to stop being about the money. If a patient says to you, "I have a sink full of dishes at home, can you wash them for me? I'll give you $600." Are you going to take that offer?

For me, personally, I don't have the luxury of turning this work away. If I stopped nails, all I would have is empty space on my schedule. Yep we need more schools alright.

What I don't get is some of you hospital employed folk who are busy doing actual medical care for people with real problems saying "I trim nails only under XYZ circumstances" when you could just tell these pts to F off. Tell your overlords you're a busy doctor and nailcare diverts your skill and attention from actual patients who rightfully deserve your care. Why bother quoting an FU price when you can just say FU.



All nails need to be trimmed the same way all teeth need to be brushed and all butts need to be wiped. I'm being a broken record here, but in a sane universe, nail care is not considered a medical treatment under any circumstances and anyone can go to a licensed nail tech for the same price as a supercuts haircut.

However in the timeline we occupy, nailcare is free under a specific set of circumstances that can only be determined by a doctor with 7 years of training and these findings need to be carefully documented each visit.

You never outright turn patients away if you are hospital employed. You just don't have the luxury to do that as a podiatrist employed in a hospital. Maybe ortho and other higher paying specialties can but podiatrists don't have that kind leverage.

Any negative feedback from a patient that goes straight to admin is frowned up and you will get a phone call from your lead admin asking what happened with XYZ patient.

If you went out of your way to explain the process and offer the ABN and they refuse then you have covered yourself

Use the ABN aggressively. Preferably before they step into the clinic and over the phone. All your problems will be resolved.

 

[Bluecollarmed]

100% agree on ABN. I finally got the hospital to adopt that and they sign it when they check-in. People coming for an annual diabetic exam that don't meet PAD or neuropathy or prior amp also get a phone call prior by the nurse to let them know that nail trimming may not be performed if they don't meet findings or an ABN is signed. We don't schedule "nails and calluses" but you know how it is, these people schedule for foot pain or onychomycosis or an ingrown etc... Luckily I'm at a place where they see that $35 and a CNA/MA is doing nail care so why would they want those visits taking place by the surgeon. It's honestly a no brainer from a hospital standpoint if you're busy to separate these people in favor of something that might hit the OR.

 

[DYK343]

What I don't get is some of you hospital employed folk who are busy doing actual medical care for people with real problems saying "I trim nails only under XYZ circumstances" when you could just tell these pts to F off. Tell your overlords you're a busy doctor and nailcare diverts your skill and attention from actual patients who rightfully deserve your care. Why bother quoting an FU price when you can just say FU.

The half day I do nail care is by far my most profitable day.

But again I only do trainwrecks (E&M) and see 5ish an hour.

Most come out to 1.8wRVU.

I generate 30-40 wRVU morning clinic alone.

Im considering making it a full day if the volume is there.

I typically generate about 30-40 wRVu in a full day of MSK clinic. Add on inpatient rounding and a morning surgery and im typically around 50ish wRVU a day.

...Except my nail care day is usually about 60-70 wRVU for the day.

 

[Feli]

Hospital employ docs will have to do whatever their admins say they do. Ditto for PP associates, MSG or ortho associates, etc. They'll either do what is expected, or they have to try to come to some understanding with those admins. Refer to one of the best memes ever.

...For PP owner (OP question), I agree the nail care is a pain. I'm with you on not wanting to delegate that stuff to MAs or an associate. You get some wound debrides and derm/nail procedures and injects or DME from those pts, but the billing is not fun. I really get a kick out of those seniors who complain of the $14 left as a balance for nails/calluses after insurance... they whine or refuse to pay or tell you that "Dr. X never made me pay that in the past"... yet they're happy to tell you how great their Alaska or Brazil or Hawaii trip was last month. 🙃

As far as the charging cash rate for all nail care pts, I don' think you can do that. If you're in network with their insurance (MCR or others) and they "cover" the service (even if they pay slow or not at all), you're required to bill that stuff to that insurance. If it's a self pay patient or a payer you're not contracted with, obviously whatever goes (cash rate).

I just look at it as a taking the bad with the good situation. You will do great on e/m and DME and OTC and most office procedures (compared to any kind of employed DPM). It's almost impossible to practice podiatry without Medicare, so maybe just try to mitigate the nail care visits by scheduling them 3 or 4 months out and hoping they go to a local competitor? You could flat out refuse them if you have plenty of appointment demand for other stuff?

There are plenty of gen surgeons who don't accept "bariatric patients." Many many OBGYN only do the gyn part (mostly malpractice, but also preference). A lot of specialists only do limited scope in one form or another. Other docs are intentionally OON so they can set their own cash rates (likely the derm or plastic docs you speak of in OP). Sure, people expect podiatry to do routine foot care, but you can limit scope if you want. The problem becomes if you do accept the insurance plan and the patient comes in with a chief complaint you don't want... those have to be caught on the front end. GL

 

[Hybrocure]

Sorry, why are the RVU guys chirping in a TFP thread?

We don’t speak that language.

This thread is for poors only

 

[air bud]

My partner did a fair bit of "Cash for keratin," and since he retired we raised our prices from $57 to $60. You would not believe the outrage my secretaries faced. My Google reviews have taken a nose dive but at least I'm offloading these pts to the poor sap in the next town.

Which brings me back to my point above. At a certain level, it has to stop being about the money. If a patient says to you, "I have a sink full of dishes at home, can you wash them for me? I'll give you $600." Are you going to take that offer?

For me, personally, I don't have the luxury of turning this work away. If I stopped nails, all I would have is empty space on my schedule. Yep we need more schools alright.

What I don't get is some of you hospital employed folk who are busy doing actual medical care for people with real problems saying "I trim nails only under XYZ circumstances" when you could just tell these pts to F off. Tell your overlords you're a busy doctor and nailcare diverts your skill and attention from actual patients who rightfully deserve your care. Why bother quoting an FU price when you can just say FU.



All nails need to be trimmed the same way all teeth need to be brushed and all butts need to be wiped. I'm being a broken record here, but in a sane universe, nail care is not considered a medical treatment under any circumstances and anyone can go to a licensed nail tech for the same price as a supercuts haircut.

However in the timeline we occupy, nailcare is free under a specific set of circumstances that can only be determined by a doctor with 7 years of training and these findings need to be carefully documented each visit.

I do indeed say FU. Rather, my amazing awesome don't mess with her front desk person tells them this for me. Drugs and nail care just say no.

 

[Sybly]

Is it legal to only accept self pay for routine nail care in the private practice setting ?

Regardless of insurance type or coverage, qualifying modifiers, diabetes, laziness, etc, etc....


Reasoning:
No matter how much I discourage routine nail care, I will have endless patients requesting this service.

1. I don't consider this to be worth the time and hassle. It was nice to fill the schedule a few years ago. I don't want to have a team of MA's performing nail care for me either.

2. I find my billing team and office staff spending just as much time chasing down payments from odd ball primary and secondary insurances and Medicare replacement plans in hopes of getting paid a few bucks for this service. They are chasing 45$ instead of 450$.

3. Yeah, I get a few random nail care patients that lead to TNC, MTH excision & other higher paying CPTs. However, majority of those patients I find will locate me directly for those problems as new patients. So, I don't appreciate too much added value in keeping RNC around.

4. I get several patients that "semi" qualify for routine nail care and the ones that don't will argue indefinitely that the previous TFP in California or Kansas or wherever saw them every so many weeks and they never had to pay. Or, "my insurance says I get my nails done 3x per year no matter what" (I absolutely don't like a patient telling me what should or should not be covered).

5. In the recent past I have heard a few stories about pods getting audited by insurance over routine nail codes. I would absolutely have a stroke if I got audited for this reason and had to pay any fines. I would probably submit my CV to Buc-ee's or move to Greenland at that time.

Bottom line: Can I accept cash only or is my only option to punt them to another doctor at initial request ?



Outside example:
I have derm & plastic friends that perform blepharoplasty as self pay only option.
I was told that if you have medical documentation that 30% of vision is obstructed that this is insurance covered procedure.
However, these doctors simply tell even the low vision patients that if they want the service possibly covered by insurance then to go elsewhere.

Problem is new graduates. They have to work nursing home groups and bill by thousands nails and callous.. Sad .. trouble ahead with announcement of audits on E And M plus procedure

 

[Sendin_Toes_2market]

I saw 20 today. 8 NP, 2 PF fu, 2 Post ops, 1 wound and 7 nails. All either diabetic or Q8. 6/7 had a 99213-25. Pays better wRvU than PF f/u…

I only see nails in a 1.5-2 hour window. I’d be stupid not to do them to hit my bonus…

 

[Feeter]

I'm hospital based. I have an NP who does the routine foot care that qualifies. We still don't see non qualified RFC unless they sign an ABN.

The ABN has a 95% kill rate in my practice. Once they see the prices they refuse to sign and leave. No fights or screaming.

I have my nurses screen these routine foot care patients before we see them and call them most of the time. If they have no qualifiers then we tell them they need to sign the ABN. This is done over the phone. Once they hear the prices they just cancel their appointment.

We do the same thing but we are at a point where the cost of calling and APPs performing nail care is not worth it. We may have to just make a blanket policy that our division doesn't do nail care and end this issue permanently.

 

[Adam Smasher]

We do the same thing but we are at a point where the cost of calling and APPs performing nail care is not worth it. We may have to just make a blanket policy that our division doesn't do nail care and end this issue permanently.