Private Practice docs and the new rules on skin subs

[billBOB213]

Admittedly I don't bill for these as I am at an FQHC that doesn't pay for them (btw, if anyone who does work at an FQ knows how to get them paid for pls DM me), but these new policies on skin subs will most likely have some big consequences for our profession.
Any PP owners out there that can comment on it or even those at hospitals, have they been informing you all regarding this and mandating any changes in practice? Seems like a big mess waiting to happen.
I tried to look up a thread already on this but didn't find any, if it's a repeat my apologies.

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[Pronation]

Good. It’s about time.

And good riddance these pods and WCCs that put these grafts on weekly.

 

[Boba Foot]

I think it’s good policy. If you’re not seeing progress after 4 skin substitute applications, then there’s something else interfering with the healing process that a graft isn’t going to help. People doing 8, 9, 10 applications were 100% abusing the system and just using grafts for “practice management purposes”.

 

[Retrograde_Nail]

Admittedly I don't bill for these as I am at an FQHC that doesn't pay for them (btw, if anyone who does work at an FQ knows how to get them paid for pls DM me), but these new policies on skin subs will most likely have some big consequences for our profession.
Any PP owners out there that can comment on it or even those at hospitals, have they been informing you all regarding this and mandating any changes in practice? Seems like a big mess waiting to happen.
I tried to look up a thread already on this but didn't find any, if it's a repeat my apologies.

This is not a problem.

If you did a good surgery (wound recon with diabetic offloading procedures) you shouldn’t need skin subs more than 3-4 times after to get the rest of the wound to heal.

People also need to learn how to use basic dressings to do wound care.

The only people who will suffer are crooked podiatrists putting weekly skin subs on that plantar midfoot Charlot ulcer for 3-6 months. A wound that has zero chance of healing without recon.

 

[Jummy Biffett]

Yep, the skin sub gold rush is coming to an end. The major impact will be on the companies that sell these grafts obviously, say goodbye to all the free steak dinners residents

 

[Retrograde_Nail]

Yep, the skin sub gold rush is coming to an end. The major impact will be on the companies that sell these grafts obviously, say goodbye to all the free steak dinners residents

A wound care company took me out to dinner last night. I need to secure that consultant deal ASAP

 

[billBOB213]

This is not a problem.

If you did a good surgery (wound recon with diabetic offloading procedures) you shouldn’t need skin subs more than 3-4 times after to get the rest of the wound to heal.

People also need to learn how to use basic dressings to do wound care.

The only people who will suffer are crooked podiatrists putting weekly skin subs on that plantar midfoot Charlot ulcer for 3-6 months. A wound that has zero chance of healing without recon.

I agree with this, on most cases. I also know that since residency (been out 4 years) I have had to get more creative due to the no skin subs where I work, and surgical cases for chronic wounds has been very successful in a lot of cases. These cases are fun, you use your biomechanics alot and are trying to get the patient an ambulatory foot and get them out of your clinic. Some of these poor patients with their wounds that are in clinics weekly for what seems to be years. What a different a gastroc and PL tenotomy can make for some up my recalcitrant sub-1 wounds.

Anyways, back to the thread, just wondering as I saw that report of the new changes.

 

[diabeticfootdr]

Admittedly I don't bill for these as I am at an FQHC that doesn't pay for them (btw, if anyone who does work at an FQ knows how to get them paid for pls DM me), but these new policies on skin subs will most likely have some big consequences for our profession.
Any PP owners out there that can comment on it or even those at hospitals, have they been informing you all regarding this and mandating any changes in practice? Seems like a big mess waiting to happen.
I tried to look up a thread already on this but didn't find any, if it's a repeat my apologies.

I can’t remember the last time I needed more than 4 applications. Not once since being in Texas.

But I think there needs to be an option for larger ulcers, like venous leg, which I don’t see a lot of.

 

[Adam Smasher]

skin subs were never the mainstay of my practice, not even the mainstay of my treatment protocol in wound care. I honestly have no idea how people were making so much money off of these products. The audit risk is too high and the reimbursement is slow. Claims need to be appealed. Maybe just my own bad luck.

When I did use them, and when they did work, it was on wounds that were utterly stagnant that have made their way up the reconstructive ladder and they would heal millimeter by millimeter, so I would apply 6-8 in a row.

 

[Retrograde_Nail]

I can’t remember the last time I needed more than 4 applications. Not once since being in Texas.

But I think there needs to be an option for larger ulcers, like venous leg, which I don’t see a lot of.

Venous leg ulcers can benefit from skin sub application I’ve found more success with mesalt and unna boot wraps than using skin subs.

Then try and find a vascular surgeon who is interested enough to do a vein ablation.

 

[Pronation]

I can’t remember the last time I needed more than 4 applications.

Oh wow, that is definitely some fellowship level skill right there.

 

[Adam Smasher]

Regranex is better anyway

 

[Hybrocure]

What’s the deal with the grafts that people are making thousands per application on? Are these legit or does it get clawed back

 

[GreenHousePub]

What’s the deal with the grafts that people are making thousands per application on? Are these legit or does it get clawed back

Some get clawed back, like 24 million dollars worth:

Beverly Hills Plastic Surgeon Agrees to Pay Nearly $24 Million to Settle False Claims Act Allegations

A plastic surgeon in Beverly Hills, California, along with his son, medical practices, and billing company, have agreed to pay $23.9 million to resolve allegations that they violated the False Claims Act by submitting or causing the submission of false claims to both Medicare and Medicaid.

www.justice.gov

 

[billBOB213]

 

[icebreaker32]

What’s the deal with the grafts that people are making thousands per application on? Are these legit or does it get clawed back

Some are making profits of several hundreds (maybe a thousand or more in some cases) per application with the right product, the right insurance and the right secondary insurance and right place of service. If all those do not line up it is often a much, much less profitable situation.

 

[Feli]

Good. It’s about time.

And good riddance these pods and WCCs that put these grafts on weekly.

Yeah, I'm as PP as can be, but I don't use them.

I do this weird stuff called EBM.

 

[BubbaWub]

Yeah, I'm as PP as can be, but I don't use them.

I do this weird stuff called EBM.

Yes, I love EBM. Most of my practice is based on EBM. Emery Board Maneuvers, these techniques are taught from myself to chief resident only at my practice. It is a great wave of the future that most of our graduates would be lucky to learn. I appreciate you Feli for engaging in a similar practice style such as myself. I am proud to call you a member of my organization.

Thank you.

 

[DYK343]

What’s the deal with the grafts that people are making thousands per application on? Are these legit or does it get clawed back

They dont pay that well.
3ish wRVUs which is about $150.
Not sure private reimbursement. But I doubt its thousands per application.

I rarely use them. They do have their place but its once every 6 months for me.

 

[heybrother]

They dont pay that well.
3ish wRVUs which is about $150.
Not sure private reimbursement. But I doubt its thousands per application.

I rarely use them. They do have their place but its once every 6 months for me.

The first thing people need to understand about this is - to the best of my knowledge - all of the graft shenanigans were only happening on Medicare. The reps would tell you they were looking into BCBS, but that was never the way the game was played. Medicare + secondary was what everyone wanted the patient to have because that was who paid.

The money wasn't made on the preparation code. It was made on the surplus payment over cost on the graft itself. I don't understand it, but graft reps were coming to my office claiming I'd make $800+ over the top on some of the grafts. They'd point to specific products claiming right now this or that product was more profitable and that the bigger the wound and graft the more money there was to be made. A friend of mine left an office where he claimed the office was up like $300K on grafts and that is was the back bone of their cash flow.

There are other products in medicine where people essentially are reimbursed higher than the cost of the medication (ie. chemotherapy which is supposedly a large part of why oncologists are paid so well right now), but I'm not quite sure why this whole thing was worth so much money.

The story awhile ago was that people billing grafts were going to have to submit how much they paid and how much they were reimbursed.

Anyway, I'm having a hard time feeling bad about this whole scenario. I like people being able to have the products that they need. But docs were literally EXCITED about grafts. The first conference I went to where graft people were at everyone I spoke to was talking about how much money there was to be made.

 

[billBOB213]

Wow I must say, I thought more people would be using them-and I’m not even talking abusing the system, but actually ‘using’ them appropriately and frequently.
I went to a residency program at a county hospital, tons of surgeries (trauma, DM train wrecks) and clinically got to use a decent amount of skin subs. But being that I don’t practice being able to use them I just figured more people did. Funny what you imagine is going on outside your practice….


I do miss those steak dinners in residency tho
#tomahawk

 

[DMEpod]

Use them pretty regularly in PP. Good reimbursement makes it worthwhile. Honestly think I've used more than 4 on just a couple pts. Usually if the ulcer gets small enough to where the graft is much bigger than the actual ulcer I stop. I'm sure in a year or two these companies will come up with some work around billing for this that pods will start using. I know of plenty of practices that this will impact their bottom line heavily though.

 

[Adam Smasher]

The money wasn't made on the preparation code. It was made on the surplus payment over cost on the graft itself. I don't understand it, but graft reps were coming to my office claiming I'd make $800+ over the top on some of the grafts. They'd point to specific products claiming right now this or that product was more profitable and that the bigger the wound and graft the more money there was to be made. A friend of mine left an office where he claimed the office was up like $300K on grafts and that is was the back bone of their cash flow.

bingo.

You are reimbursed per unit, and one unit = 1 sq cm. The loophole is that the OG grafts--dermagraft and apligraf--are sold in one size fits all, 38 and 44 sq cm, resepectively. So you multiply your profit margin by 38 or by 44 and it adds up to $$$ per session. As for the other grafts, there was always a gentleman's understanding that it was abusive to apply a 25 sq cm product to a 1 sq cm wound, but never explicitly prohibited. Meanwhile a lot of these companies offer a price break per sq cm when ordering a big graft, so the more you waste, the more you can earn.

 

[heybrother]

The word to describe what's going on here is arbitrage. Grafts and DME with Medicare both fall into this category. You can buy a CAM boot for $25 and charge Medicare $270. Its problematic to me because what I would really like is to be reimbursed for the work I actually do.

 

[Feli]

... Medicare + secondary was what everyone wanted the patient to have because that was who paid...
...The money wasn't made on the preparation code. It was made on the surplus payment over cost on the graft itself. ..

Yessir^

...I know of plenty of practices that this will impact their bottom line heavily though.

For sure.

The supergroup I left sends all associates a list of "graft eligible" patients monthly to encourage them to use them. There is a large markup on the (fake) graft versus its cost to the group/office (particularly if you arrange bulk rates on a certain graft for large/super group!). The application and debride + visit also pays, but not nearly so much. It's about the markup on the (fake) graft itself.

...I would not doubt if bits of kleenex applied to the wound using steri-strips to secure it would have similarly helpful results to said "grafts"... assuming combined with proper wound debride, abx, revasc, offload, compress, as applicable. I am glad this nonsense is over. YMMV

 

[Hybrocure]

bingo.

You are reimbursed per unit, and one unit = 1 sq cm. The loophole is that the OG grafts--dermagraft and apligraf--are sold in one size fits all, 38 and 44 sq cm, resepectively. So you multiply your profit margin by 38 or by 44 and it adds up to $$$ per session. As for the other grafts, there was always a gentleman's understanding that it was abusive to apply a 25 sq cm product to a 1 sq cm wound, but never explicitly prohibited. Meanwhile a lot of these companies offer a price break per sq cm when ordering a big graft, so the more you waste, the more you can earn.

Is Apligraf the pee-pee graft?

 

[air bud]

They dont pay that well.
3ish wRVUs which is about $150.
Not sure private reimbursement. But I doubt its thousands per application.

I rarely use them. They do have their place but its once every 6 months for me.

Narrator: it is thousands per application

 

[MicroPod]

One of the attendings (PP partner, has been out of residency over 10 yrs) we work with in my residency started doing grafts the last couple of years along with oxy mist treatments. He claims that he doubled his take home just by incorporating those two things into his practice. The rep basically lives at his practice lol.

 

[dtrack22]

Then try and find a vascular surgeon who is interested enough to do a vein ablation.

Good luck. It’s actually probably not hard in larger metros but even if you aren’t totally rural…our local regional hospital has a vascular group but since they are busy, they stopped doing any vein work. Closest place I can get my patients now is about 3 hours away.

They dont pay that well.
3ish wRVUs which is about $150.

Well your coders suck, but depending on the MAC you can bill both the wound bed prep and the skin sub application codes together, even on subsequent applications. That’s 6.4 wRVU on a foot wound.

I don't understand it, but graft reps were coming to my office claiming I'd make $800+ over the top on some of the grafts. They'd point to specific products claiming right now this or that product was more profitable and that the bigger the wound and graft the more money there was to be made.

You bill the Medicare approved invoice price per unit of the product you use. The company that sold you the graft has a huge profit margin and will offer you a 20-40% “rebate” on the cost of the graft after you’ve paid them for it. So you bill Medicare $2000, patient has a secondary so you get reimbursed $2000. You pay your invoices to the company (none of them require payment until after you’ve been paid now) and they send you a rebate for $600 for that one graft you used. $2000 is not a large charge for these products on a reasonable sized wound…I billed $16000 for a graft once and I’ve heard of people billing more in the case of larger wounds.

The loophole is that the OG grafts--dermagraft and apligraf--are sold in one size fits all, 38 and 44 sq cm, resepectively. So you multiply your profit margin by 38 or by 44 and it adds up to $$$ per session. As for the other grafts, there was always a gentleman's understanding that it was abusive to apply a 25 sq cm product to a 1 sq cm wound, but never explicitly prohibited. Meanwhile a lot of these companies offer a price break per sq cm when ordering a big graft, so the more you waste, the more you can earn.

I’m not sure this is true. I know it’s not true for most organogenesis, mimedix, etc. products now a days. When you submit your 1500 (claim form) you indicate the number of units actually used on the wound as well as the $/unit of the product. In the note you document units used and any “waste.” I don’t believe there is any incentive to “waste” any product, in fact, other than (maybe) dermagraft/apligraf I’m fairly certain it’s the opposite.

 

[icebreaker32]

One of the attendings (PP partner, has been out of residency over 10 yrs) we work with in my residency started doing grafts the last couple of years along with oxy mist treatments. He claims that he doubled his take home just by incorporating those two things into his practice. The rep basically lives at his practice lol.

Podiatry has always been this way. Chasing the next golden goose. Not uncommon at all year after year it is one or maybe two type of services used and often abused by many in PP that helps them make higher than an associate's salary in solo practice. Owners with associates and not partners make $$$ of protocols that incorporate the golden goose.

I know one podiatrist well in a well rounded suburban practice billing over 500,000 a year on grafts the last couple of years. They are not depending on just that, but doing well from it. I know of others it just never works out to have the right patients and the right insurances etc to make it worthwhile.

 

[dtrack22]

the right patients and the right insurances

All they need is Medicare and a secondary. That’s the ticket. You can slap on $50,000 worth of grafts and patient doesn’t care at all because they don’t pay a penny for them.

If the company you use offers a 30% or greater rebate, then Medicare alone works and you can eat the patients 20% co-insurance that they can’t afford. I’m pretty sure that’s called “Medicare fraud” but this is Podiatry after all…

 

[air bud]

All they need is Medicare and a secondary. That’s the ticket. You can slap on $50,000 worth of grafts and patient doesn’t care at all because they don’t pay a penny for them.

If the company you use offers a 30% or greater rebate, then Medicare alone works and you can eat the patients 20% co-insurance that they can’t afford. I’m pretty sure that’s called “Medicare fraud” but this is Podiatry after all…

first of all it 40 percent....and you send them the bill and say hey just ignore this we won't come after you....

 

[msion]

There is a reason why the reps are now targeting at inpatient cases. Outpatient is now heavily audited.
I typically don't get any attention from the reps in the hospital because: 1. I stick with whatever is cheapest in the OR; 2. I value my family time so never go to dinners with them or anybody really.

But lately they have been approaching me asking if I would like to throw some amnio or fish skin on my I&Ds or TMAs. Not that I don't use biologics...maybe Integra from time to time, or I harvest skin from the thigh, or reverse sural for calcanectomies on the few patients that I like. But I really don't know if these amnio grafts work any better than my current way of treatment. Plus these products will likely inflate my case cost and catch OR attention.

Back to outpatient grafts. When I first started the job I did use grafts on wound care patients for 3 months. I made so much money from those 90 days that I couldn't sleep well at night. And it just happened to be that my wife was watching "Orange is the New Black". I had some wild dreams those days. And then I pretty much stopped using them altogether. Practice owner at the time wasn't super happy about it. But I could sleep better, so who cares.

 

[DogSnoot]

When I first started the job I did use grafts on wound care patients for 3 months. I made so much money from those 90 days that I couldn't sleep well at night.

no amount of money is worth going to jail or prison. Glad you got out of that habit fast and I hate that your boss pressured you.

 

[Hybrocure]

How are the prisons for doctors these days? Like do you get sent to special ones or special wards or do they toss you in with the violent guys too. Also how do student loans work when you’re locked up

 

[619]

How are the prisons for doctors these days? Like do you get sent to special ones or special wards or do they toss you in with the violent guys too. Also how do student loans work when you’re locked up

As a doctor in prison, you can opt to treat wounds and clip toenails of fellow inmates in the specialty clinic in exchange for reduced prison time.

For student loans, you switch to the new Biden INMATE payment plan. Loans forgiven only for those serving life. The few on death row still need to worry about their loans though.

 

[air bud]

I figure nail care is a great way to trade for Loosies

 

[Hybrocure]

As a doctor in prison, you can opt to treat wounds and clip toenails of fellow inmates in the specialty clinic in exchange for reduced prison time.

For student loans, you switch to the new Biden INMATE payment plan. Loans forgiven only for those serving life. The few on death row still need to worry about their loans though.

Will the reps put money on your books if you listen to their sales pitch over the phone?

 

[Boba Foot]

But lately they have been approaching me asking if I would like to throw some amnio or fish skin on my I&Ds or TMAs.

The fish skin actually works pretty well and it's a fraction the cost of Integra.

 

[FutureDPM323]

Yea doesnt Integra cost a lot anyways? I remember when I was on an off service rotation one of the surgeons I worked with talked on and on about how expensive Integra is and how there are much cheaper alternatives that work just as well. Granted he did say there’s a time and place for using it but he just feels it’s a product that’s overused especially given it’s cost

 

[Boba Foot]

I like the silicon layer of Integra. Whether it actually helps, or just makes me feel more comfortable, I like the layer to help with physical coverage of the wound. However, one time an Integra rep showed up to one of my cases without product, so I quit using them and results have been equally as well using the fish skin.

 

[DYK343]

I like the silicon layer of Integra. Whether it actually helps, or just makes me feel more comfortable, I like the layer to help with physical coverage of the wound. However, one time an Integra rep showed up to one of my cases without product, so I quit using them and results have been equally as well using the fish skin.

I havent done the fish skin yet.
I keep hearing talk about it.

I do like Integra. I never use it. But its good stuff.

 

[Feli]

CMS Statement on Proposed Local Coverage Determination (LCD) for Skin Substitute Grafts/Cellular and Tissue-Based Products for the Treatment of Diabetic Foot Ulcers and Venous Leg Ulcers | CMS

CMS is aware that on April 25, 2024, the Medicare Administrative Contractors (MACs) released a proposed Local Coverage Determination (LCD) to provide appropriate coverage for skin substitute grafts used for chronic non-healing diabetic foot and venous leg ulcers.

www.cms.gov