Starting a cash pay podiatry practice

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This thread has been very informative! Thank you all!

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You guys are killing this thread. @Creflo has no need to defend himself to anyone on this forum and none of us has any right to demand explanations from him. Offering advice is one thing, but demanding explanations on an internet forum like this is just ludicrous. This thread has been very popular and beneficial, and let's try to keep it headed in a positive direction

ldsrmdude,

I respect and understand your thoughts and comments. I never demanded explanations from creflo. If you note, my original comment actually commended him for his efforts.

However, I expressed some concerns for a few reasons. Please also note I did not make accusations, I simply inquired.

The first reason is because I thought maybe creflo hadn't thought about some of my concerns. When we are young and hungry, we often forget or miss details. As someone who's reviewed and testified on similar types of scenarios, I made my comments in an attempt to possibly protect creflo or act as an "ah-ha" moment.

I also think that our profession has the responsibility of protecting the public and making sure patient safety is paramount.

I never wrote that creflo isn't using a sterilizer, I simply asked how he's sterilizing his instruments between patients.

This forum has educational benefits for students, residents and attendings. Those who are young, learning and impressionable should have answers for these questions.

On an anecdotal note, in our area there was a local young doc providing similar home and nursing home services. He was using a "hot bead" sterilizer. I was asked to review his safety protocol and recommended he not use the hot bead sterilizer (check the real literature, not the literature supplied by the manufacturer). He was naive and listened to a salesman, thanked me for my recommendations and our office allowed him to use our autoclave until he was able to afford his own.

Our profession gets enough bad press. Starting off a practice on the wrong foot doesn't help that reputation. Again, I'm not saying Creflo is doing anything wrong, I simply asked to educate the young and impressionable docs in training.

As adults, I see nothing wrong with back and forth conversations, even if there are opposing views, as long as it remains respectful without mud slinging.

Thanks.
 
Creflo, please continue updating us. I appreciate reading about your travails.

Questions and concerns that could potentially harm a colleague should probably be via private message. That's what I would want.
 
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Creflo, please continue updating us. I appreciate reading about your travails.

Questions and concerns that could potentially harm a colleague should probably be via private message. That's what I would want.

Understood. My intention is not malicious, nor would I want to hurt a colleague. I thought that his answers may educate those who may want to follow Creflo's foot steps.

It would be nice to know how he overcame some of the issues I've discussed.
 
Had to re-invoice one patient's family, but they paid. All accounts receivables are current. Saw some nursing home patients this week, one new one and some follow ups. Was offered a gig working on saturdays for a local podiatry group, not house calls. They would fill the day with patients, provide support staff and billing, and pay me 35 to 40%. I plan to stick with my own practice for now. I never heard anything about the ethics investigation at my government job, so asked my boss for clarification, will have a meeting next week with my boss and the next higher up boss.
 
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Found the results of my ethics investigation, no ethical violations were found. But was told to give a talk to my department about how to handle off duty employment. It's likely that the ones who turned me in for violations will be in the audience.

Got a foldable rolling cart, should come in handy with nursing home visits.
 
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So my car is about 9 years old, American made, something's always breaking on it. The last issue was the trunk stopped opening. I was able to fix with a drill and a $3 switch from the hardware store. Then this week the car stopped shifting into reverse. So at my day job yesterday I'm doing an ORIF, and when I'm done I have to physically push my car out of the parking place at the surgery center. It was nice that my screw and plate rep was leaving at the same time, he helped me push the car out. I noticed afterwards he got into his new Lexus, it pulled out just fine.
 
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So my car is about 9 years old, American made, something's always breaking on it. The last issue was the trunk stopped opening. I was able to fix with a drill and a $3 switch from the hardware store. Then this week the car stopped shifting into reverse. So at my day job yesterday I'm doing an ORIF, and when I'm done I have to physically push my car out of the parking place at the surgery center. It was nice that my screw and plate rep was leaving at the same time, he helped me push the car out. I noticed afterwards he got into his new Lexus, it pulled out just fine.
My MCAT results are due next Tuesday. I joke with people that if it is too low I'm pretty sure I can line up a sweet gig at the local Burger King. Now I'm wondering if I need to line that gig up even if my MCAT is reasonable. You know, supplemental income for car payments and such......
 
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what has this turned in to now lol
 
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So my car is about 9 years old, American made, something's always breaking on it. The last issue was the trunk stopped opening. I was able to fix with a drill and a $3 switch from the hardware store. Then this week the car stopped shifting into reverse. So at my day job yesterday I'm doing an ORIF, and when I'm done I have to physically push my car out of the parking place at the surgery center. It was nice that my screw and plate rep was leaving at the same time, he helped me push the car out. I noticed afterwards he got into his new Lexus, it pulled out just fine.
You are definitely inspiring me to not work for the government.
 
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You are definitely inspiring me to not work for the government.

Same here, this thread has been extraordinarily depressing I just didn't want to say anything. I know a medical examiner 9 years out from a 5 year residency and fellowship that makes a whopping $155K/year at a large major city. I'm already marking government (especially DVA) off my list. I do appreciate the effort and interesting insights from the OP, however. I enjoy learning about all spectrums of practice.
 
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Got a call today from a prospective patient for finger swelling secondary to cervical spine problems, had to turn him away.

Decided to call Medicare to check the status of my application that my new billing company completed about 2 months ago. Just have had an uneasy gut feeling about the billing company that increases almost every time we talk. No record of my application according to Medicare. So parted ways with the biller.

Saw a vacationing patient the other day for an ingrown, actually treated her outside, ocean in view. Texted her a couple of days later to check in, she was pain free, enjoying her vacation without pain pills.

Car goes into reverse now, $20 part from auto zone thankfully. Treated myself to new subwoofer, came in today. Should make the commute to the nursing home more fun.
 
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Had to re-invoice one patient's family, but they paid. All accounts receivables are current. Saw some nursing home patients this week, one new one and some follow ups. Was offered a gig working on saturdays for a local podiatry group, not house calls. They would fill the day with patients, provide support staff and billing, and pay me 35 to 40%. I plan to stick with my own practice for now. I never heard anything about the ethics investigation at my government job, so asked my boss for clarification, will have a meeting next week with my boss and the next higher up boss.

Is it possible to pick up clients from this nursing home? I'm guessing most would be on medicare so maybe down the line it might be worthwhile.
 
Got a call from a new patient who lives down a dirt road. He said he can pick me up if it's too rough for my car. He must have me confused with the hardware rep. I told him my car isn't fancy. I googled him and it turns out he was arrested a while back for misbehaving at a city council meeting. He's out of jail now, I'll be sure not to mention the arrest.
 
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Got a $20 tip from yesterday's patient who said you tip the pizza guy, so you should tip the foot dr.

There were flies flying around today's patient, reminded me of my third year of pod school when I was doing an ingrown procedure on an elderly gentleman. Just as I was removing the ingrown portion of nail, he asked for his empty peanut butter jar. I told him I could get it for him in just a minute, but needed to finish the procedure. He said no, he needed it now. So I reached over to his bag, got the jar. He unscrewed the top, pulled up his shorts, and did #1 while I finished the procedure. We both finished about the same time.
 
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Haven't been posting lately, thanks for checking in. Practice is alive and well. Just this morning had a patient throw their milkshake on me. Got my lab coat pretty good and my scrubs, but my face and hair were spared. And it was the first patient of the day. Next time I'm gonna take her meal tray away before I treat her.
 
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Haven't been posting lately, thanks for checking in. Practice is alive and well. Just this morning had a patient throw their milkshake on me. Got my lab coat pretty good and my scrubs, but my face and hair were spared. And it was the first patient of the day. Next time I'm gonna take her meal tray away before I treat her.
They threw it on you on purpose because you did something they didn't like?? Or accidental??
 
I have loved reading through this thread. I hope that your practice is doing well and continuing to grow. Do you have any updates for us?


Sent from my iPhone using SDN mobile
 
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Hope all is going well with you...not even a dpm but stories like these makes me want to root for the guy. @Creflo
 
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So I'm technically still employed by the government job for one more day, then I'm free (and without the paycheck). I have continued the moonlighting cash/medicare practice over the past months. The milkshake thrower has been calmer the last few visits.

I have spent the last 11 months learning how to bill medicare. I figured I could learn on my own since I'll primarily be using nail cutting and callous codes. Countless hours listening to our national association's webinars, studying websites, listening to podiatry billing seminars, working my way through a few different billing companies (I guess it's hard to get top level service when you are their smallest client), and paying seasoned podiatrists in other states $100 to $200 per hour for their time, has brought me to the point where I feel confident in my ability to code toenails and calluses. I also feel pretty good about my ability to determine the e&m level for most visits and how to use some of the basic modifiers.

I'm up to three assisted living facilities, with a couple more in the pipeline. Will also be doing some part time podiatry work to replace my old day job.

As for my former government job, all ended well. I even got an award from the head of the hospital for my service there. The job overall was tremendous, the patients were great, and I collected enough cases for the surgical board.
 
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Well I decided to revive the thread. Today got bit 2 times by a three legged dog during a house call. Soon I'll update you on the past 4 years.
 
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Your car still working? Mines still kicking from back then as well. Past month all of the systems gradually turned off while I was driving. First it was the radio, then the electric, then the power steering, then the power brakes, then everything. Luckily I was at the top of a hill and I coasted it a quarter mile right into my driveway.

Needed a new alternator. After installation found that the automatic lights turning on would take the car out of cruise, drop it into 2nd gear and turn the brights on. Culprate ended up being some LEDs lights I installed back in 2014. Took them out and it works fine.
 
My big thing I want to focus on for my practice is - cash transparency. I may be missing something, but we've created this big stupid system that looks something like this. We set insanely high fee schedule prices. The insurance company punches the prices back down to some sort of reality - sometimes still fine and sometimes awful. Cash pay patients come along and we still quote them the absurd fee schedule prices. Some pay. Others walk- it seems like easy business we are turning away.
 
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Your car still working? Mines still kicking from back then as well. Past month all of the systems gradually turned off while I was driving. First it was the radio, then the electric, then the power steering, then the power brakes, then everything. Luckily I was at the top of a hill and I coasted it a quarter mile right into my driveway.

Needed a new alternator. After installation found that the automatic lights turning on would take the car out of cruise, drop it into 2nd gear and turn the brights on. Culprate ended up being some LEDs lights I installed back in 2014. Took them out and it works fine.
Sounds like my wife's electrical work in our house. She installed a light dimmer in a bedroom, and when you dim the light the room down the hall light comes on. Car got flooded in a storm, total loss. Got a used Kia soul and the ride is bumpy but it gets beat to death with house call driving, gets the job done. Just bought an airtouch x ray, so my 3 thousand dollar car is carrying a 25 thousand dollar x ray machine.
 
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Sounds like my wife's electrical work in our house. She installed a light dimmer in a bedroom, and when you dim the light the room down the hall light comes on. Car got flooded in a storm, total loss. Got a used Kia soul and the ride is bumpy but it gets beat to death with house call driving, gets the job done. Just bought an airtouch x ray, so my 3 thousand dollar car is carrying a 25 thousand dollar x ray machine.

So you take that X ray machine from house to house??? I'm having a hard time even imagining practicing like this haha. Looks like you've been at it for about 4 years, so it must be working out. I'm looking forward to the updates.

Also it's probably good you don't drive a Mercedes--someone would probably break into it and steal your X ray machine. Kia Soul--thieves just walk on by without giving it another look...

Do you miss doing surgery at the hospitals? What kind of procedures do you do in people's homes? I mean, I sure wouldn't miss the post op visits...but I'm sure I would miss the OR.
 
So you take that X ray machine from house to house??? I'm having a hard time even imagining practicing like this haha. Looks like you've been at it for about 4 years, so it must be working out. I'm looking forward to the updates.

Crazy thing is it looks like a digital camera. Can you imagine someone getting ahold of one and just taking it out in public, irradiating themselves and others for a party-trick.

Got a used Kia soul and the ride is bumpy but it gets beat to death with house call driving, gets the job done. Just bought an airtouch x ray, so my 3 thousand dollar car is carrying a 25 thousand dollar x ray machine.

Nothing wrong with a good beater car for work. For stuff like that I always like to count: "15 more patients till the car is paid off"
 
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So you take that X ray machine from house to house??? I'm having a hard time even imagining practicing like this haha. Looks like you've been at it for about 4 years, so it must be working out. I'm looking forward to the updates.

Also it's probably good you don't drive a Mercedes--someone would probably break into it and steal your X ray machine. Kia Soul--thieves just walk on by without giving it another look...

Do you miss doing surgery at the hospitals? What kind of procedures do you do in people's homes? I mean, I sure wouldn't miss the post op visits...but I'm sure I would miss the OR.
I have privileges at only one hospital, about 2 miles down the street from where I live. But it's time consuming to go there. If something can be done in the home, I'll do it there.
 
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So there is a well known hospital system in my town that does not use podiatrists, lets call it the "Excellent Hospital". Over the past couple of years I have been referred to several of their patients by frustrated home health nurses because their wounds don't heal. This is typically how it goes: "So how long have you had that wound on your foot?" Several months. "And does Excellent Hospital care for your foot?" Yes. "What have they done for it?" They have the nurse putting a dressing on it. "Have they done an x ray?" No. "Have they sent you to a vascular doctor?" Yes, I saw one one time, they amputated my other leg. "Oh, OK." "Well, here is what I recommend, I'm going to refer you to my vascular doctor who does an excellent job in restoring blood flow by intervening to a level even below the knee, because your doppler signals are very bad. Then I'm going to actually order offloading padding to be placed around your pressure ulcer so it will have a chance to heal. Then I will see you weekly and take measurements, and we'll do all we can to heal your wound. And I'm also going to get an x ray. And then I will get an MRI becasue I think you might have a bone infection." "And when is the last time the Excellent Hospital looked at your foot?" Oh, about two weeks ago I was there, they looked at it briefly and said it was doing fine.

Then the next thing I say is "Well, I'm not a part of the Excellent Hospital, so my x ray, MRI, and vascular doctor are going to be done through me, not Excellent Hospital, and if you need hospital admission or surgery, it will be through me and my hospital." The patient says: Oh, no, I want to keep it with Excellent Hospital, they are the best in the country and they take care of all of my health issues. I say "Well, that is your perogative. And they don't have podiatrists, right?" Yes, that is right. "So you want to continue your wound care with Excellent Hospital?" Yes, I believe so. "OK, if you change your mind let me know."

A few months later, the patient calls me and says the wound care nurse said they need me to treat them. I say "Are you still with Excellent Hospital?" Yes. "Have they done anything different for your wound?" The nurse still comes out. "So how can I help you?" The nurse said you need to treat my wound. "Are you willing to use a vascular doctor, surgical, and imaging services that are outside of the Excellent Hospital system?" Well, no, they are the best and they take care of everything for me. "OK, then I can't help you, let me know if you change your mind."

Has happened over and over.
 
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So to give some background on the past few years, after my government job I moved to another state, about 8 hours away. I set up a cash/medicare only practice. I tried to get on the commercial plans. I called all the major ones. They all declined me, said their panels are full. So to help pay the bills I drove 8 hours to my old state and spent one week every 3 months seeing ALF patients. Had a friend up there who let me stay at his house. Would set up at a different ALF per day for 5 days straight. In my new home state, started doing house calls, got on the local hospital. Started getting referrals from the hospital, but since I didn't take all the insurance plans had to decline the consults. Practice grew slowly, but eventually got busy despite. Started accepting ppo and medicare advantage patients. Did an ingrown nail on a terminally ill young lady (not hospice) in her home, billed her well known ppo insurance company for the treatment. They paid me. Then a few months later they wrote me a letter and requested the money back. I couldn't make sense of the reason listed in the letter, but didn't have time to fight it so mailed a check back to them. I called the patient's husband and asked him to pay me, and he gladly paid. From that point forward I pretty much decided no commercial insurance companies for me. I am glad to see the patient, but I give them the superbill and let them pay me and file themselves. It was the best move I made. Some of the medicare advantage plans were paying me 60% of what Medicare pays. Eventually got busy enough in my home state to stop the 8 hour drive.
 
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Got a call asking me to remove staples from a man's leg, he will be coming into the office next week. He was recently laid off due to the virus, so was visiting his grandmother in a rural area and cutting down some trees. The chainsaw ripped through his pants and into his leg. The nearest hospital was over an hour away. They called 911, the operator said it would have taken over an hour for amublance to arrive. So here's what they did, they have done this before. They called the local police station, said what road they will be traveling on, described their car, and said it will have the hazards on and don't pull them over. The local police said "fine" and called the police in the next town over to tell them not to pull the car over. Then that police station called the next police station at the next town and said don't pull the car over. They made it to the ER fine without being pulled over. Sounds like Mayberry.
 
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Get a text from my main/go to home health nurse today. She is seeing a bedbound patient, the patient's dog stole her roll of tape, ran out the doggy door. Nurse goes after it and patient is bedbound with open wounds and she somehow locked herself out with her phone and everything else left inside the house. So, she had to scale a 6 foot fence and break into the patient's house with a credit card.

Earlier the same day, she is attempting to see one of my patients and he doesn't answer the door. Come to find out, the reason is he was stuck in the toilet, he fell into it and couldn't get out.
 
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Blue Cross called yesterday, said they wanted to offer me a contract. How much does it pay, I asked. They responded in vague terms, something like 85% of 2010 Medicare allowable ranging to 66% of current Medicare rates. It was confusing, so I said to simplify I basically want to be paid what Medicare pays. They said no way, they start all podiatrists with this level of contract in my state, there is no way around it, that I can negotiate for higher rates in the future. I said thanks for calling but no thanks...
 
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they start all podiatrists with this level of contract in my state

Agreed... they are dumb enough to write "tiers" on the sample reimbursement CPT list so you know there is room to negotiate albeit useless.

On flip side they do still pay for L3000 without being "code-specific" diagnosis as long as you have an LMN in medical record. Medicare excludes L3000 unless attached to a brace.
 
Blue Cross called yesterday, said they wanted to offer me a contract. How much does it pay, I asked. They responded in vague terms, something like 85% of 2010 Medicare allowable ranging to 66% of current Medicare rates. It was confusing, so I said to simplify I basically want to be paid what Medicare pays. They said no way, they start all podiatrists with this level of contract in my state, there is no way around it, that I can negotiate for higher rates in the future. I said thanks for calling but no thanks...


That was similar to my original contract. Joined an IPA 2 months later and my rates went up to around 130% of Medicare current

See if there's an IPA that you can join
 
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How long does it take to join an IPA. What is the process like

You pay them money and then you just get added on to all of the plans that the IPA is a part of. Depending on if you're already credentialed with the payers that the IPA contracts with, it can be as quick as 30-45 days. Though you do typically have to "apply" to join the IPA and be "approved" before they let you join and start adding you to the contracts, but that shouldn't take more than a month depending on how the IPA is structured. If you have to credential first, then it's no different than getting on to plans out of residency or when moving to a new area. 3, 4...6 months?
 
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Or you can accept lower rates and drink a high quality craft-brew IPA and drown out your sorrow.
 
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How long does it take to join an IPA. What is the process like

Depends on which IPA you join. They all have their own specific approval process and timeline. It also depends on the plans as well. BCBS took about a month (after joining the IPA) to start paying me at the enhanced rate, Humana took about the same time, UHC took about 6 months. The managed Medicaid plans are just now starting to pay at me at the enhanced rate (14 months later).
 
So at this point I'm not at my goal of a full cash pay practice, but I have managed to keep insurance allowed at medicare only. I still see some cash pay patients, maybe 15% of the revenue. So 2 weeks ago I received my first medicare audit, from a RAC (recovery audit contractor). It's a DME audit. I hear they work on commission, and that the reviewer is not a doctor. This is not a surprise as I have read that DME is heavily audited, so I have been meticulous with my notes. The audit is for one claim only, but I went ahead and turned it in to my malpractice carrier. I've always been a little bit nervous about administrative defense coverage with any carrier other than PICA. I tried to get PICA a few years ago and the agent blew me off. I never understood why, perhaps its because I do house calls. But it always made me wonder why they would advertise so heavily to podiatrists and then not be open to quoting me. In my state its administered by a contractor I believe, so that may be the problem. Anyway, I turned in the claim, and when the adjuster called, I asked him if I would be able to use the big names in podiatry for this type of stuff, like attorney Kevin West, or podiatrist Paul Kesselman. His response was that they use an attorney in my state that does all of these claims for them, and I asked is he podiatry specific, and he said "no, but there is a lot of overlap between podiatry and other medical specialties." That scares me, but at this stage its only for one claim, so I'll see how it goes. The attorney called me, said to forward my note to him, and sent me a contract to sign. He said the auditor will audit me one more time for more claims if I pass this one, and if I pass the second one they will lay off me for a while. He said he will not hire a coding expert on this one since it's only for one claim. Again, scares me because its vitally important to pass the first one. So I called my DME supplier who agreed to have one of their coding experts review the chart. Upon review, the expect said it looks good, but I made one typo for a small dollar portion of the claim, about twenty dollars. He said that he has seen notes that are 99% pefect fail, and he has seen bad notes pass, so he can't predict how I will fare. I emailed the lawyer 4 days ago to ask him how this may play out, if they would make a big deal over the twenty dollars, and he has not responded.

Then a week later I received a targeted probe audit from medicare, for toenail and callus codes. So I start inquiring with my malpractice insurance agent, and anyone else I can ask who may have a valued opinion, if I start turning in these claims will my malpractice premium go up due to claims frequency. The consensus is go ahead and turn it in, so that is what I did. I'm starting to feel like meat on a hook in a tiger cage with the audits and the trial lawyers on about half of the billboards in town, with their ads on TV constantly.

So I turn in the probe audit to my carrier, and call the nurse who will be handling the audit. She sends me an email with educational information about how to chart for toenails and calluses. First I wonder why nobody in podiatry school or residency has ever gotten their hands on this and distributed it to us and said "your survival depends on this." (I know the information, but I had to dig for it) Then I read through it, and I find a few concerning things. First of all, it says chronic venous insufficiency will qualify the patient for at risk toenail and callus care. I know the LCD backwards and forwards for my state, and this is not the case. So my second thought is my auditor is sending me erroneous information and thus may not be truly qualified to perform the audit. I have read that often you have to appeal the audits as the early stages are done by auditors that may not fully understand the LCD's. It says to call the auditor to acknowledge receipt of the audit. I call, she is very nice. I say I'm concerned and will give her whatever she needs and to let me know if she needs anything along the way. She says don't worry most people do fine and it will only result in education to help me. I ask her preferred method of submission. I see on the audit that it is for a time period of the prior year, but she says it is a prepayment audit and that claims will be put on hold, then they will request the chart, then if it passes they will pay, and at the end she will provide me education on anything I missed. I ask to clarify is this for claims from the last year, or claims going forward, and she gets a little defensive and doesn't really answer the question. I quickly back off and say thank you, for fear of rubbing my auditor the wrong way.

I have always wondered why at our podiatry education seminars, in podiatry school, and in residency we don't focus more on audit survival. To me this is one of the most important things we should be aware of. In my residency they taught us to fear medicare big time, and since then I have spent a ton of time and money trying to be prepared. I stand out from the typical podiatrist because I see only about 10-12 patients per day. I spend more than average time with each, and very often I use a 25 modifier as I treat more than just nails and calluses. At least in my case they more often than not have other pathologies at the same time, such as tinea, maceration, skin lesions for biopsy, ulcers, etc. It would be malpractice to ignore these things, yet if you treat them you have a target on your back with medicare. As I understand it Medicare keeps records of how my billing and coding differs from others in my specialty, and if I am an outlier, they don't like it. Since I know this, I chart with photos and extensive documentation, and keep money on the side to defend myself when they come.

I attended a seminar recently where Allen Jacobs encouraged us to not fear the "medicare police" and be real doctors, and treat more than just toenails and calluses. For me he's preaching to the choir, but medicare doesn't like it...
 
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That sucks man. Is a DME billing audit a malpractice issue? I wouldn't have been inclined to contact my carrier if no harm came to the patient. Keep us apprised of what happens next.
 
So at this point I'm not at my goal of a full cash pay practice, but I have managed to keep insurance allowed at medicare only. I still see some cash pay patients, maybe 15% of the revenue. So 2 weeks ago I received my first medicare audit, from a RAC (recovery audit contractor). It's a DME audit. I hear they work on commission, and that the reviewer is not a doctor. This is not a surprise as I have read that DME is heavily audited, so I have been meticulous with my notes. The audit is for one claim only, but I went ahead and turned it in to my malpractice carrier. I've always been a little bit nervous about administrative defense coverage with any carrier other than PICA. I tried to get PICA a few years ago and the agent blew me off. I never understood why, perhaps its because I do house calls. But it always made me wonder why they would advertise so heavily to podiatrists and then not be open to quoting me. In my state its administered by a contractor I believe, so that may be the problem. Anyway, I turned in the claim, and when the adjuster called, I asked him if I would be able to use the big names in podiatry for this type of stuff, like attorney Kevin West, or podiatrist Paul Kesselman. His response was that they use an attorney in my state that does all of these claims for them, and I asked is he podiatry specific, and he said "no, but there is a lot of overlap between podiatry and other medical specialties." That scares me, but at this stage its only for one claim, so I'll see how it goes. The attorney called me, said to forward my note to him, and sent me a contract to sign. He said the auditor will audit me one more time for more claims if I pass this one, and if I pass the second one they will lay off me for a while. He said he will not hire a coding expert on this one since it's only for one claim. Again, scares me because its vitally important to pass the first one. So I called my DME supplier who agreed to have one of their coding experts review the chart. Upon review, the expect said it looks good, but I made one typo for a small dollar portion of the claim, about twenty dollars. He said that he has seen notes that are 99% pefect fail, and he has seen bad notes pass, so he can't predict how I will fare. I emailed the lawyer 4 days ago to ask him how this may play out, if they would make a big deal over the twenty dollars, and he has not responded.

Then a week later I received a targeted probe audit from medicare, for toenail and callus codes. So I start inquiring with my malpractice insurance agent, and anyone else I can ask who may have a valued opinion, if I start turning in these claims will my malpractice premium go up due to claims frequency. The consensus is go ahead and turn it in, so that is what I did. I'm starting to feel like meat on a hook in a tiger cage with the audits and the trial lawyers on about half of the billboards in town, with their ads on TV constantly.

So I turn in the probe audit to my carrier, and call the nurse who will be handling the audit. She sends me an email with educational information about how to chart for toenails and calluses. First I wonder why nobody in podiatry school or residency has ever gotten their hands on this and distributed it to us and said "your survival depends on this." (I know the information, but I had to dig for it) Then I read through it, and I find a few concerning things. First of all, it says chronic venous insufficiency will qualify the patient for at risk toenail and callus care. I know the LCD backwards and forwards for my state, and this is not the case. So my second thought is my auditor is sending me erroneous information and thus may not be truly qualified to perform the audit. I have read that often you have to appeal the audits as the early stages are done by auditors that may not fully understand the LCD's. It says to call the auditor to acknowledge receipt of the audit. I call, she is very nice. I say I'm concerned and will give her whatever she needs and to let me know if she needs anything along the way. She says don't worry most people do fine and it will only result in education to help me. I ask her preferred method of submission. I see on the audit that it is for a time period of the prior year, but she says it is a prepayment audit and that claims will be put on hold, then they will request the chart, then if it passes they will pay, and at the end she will provide me education on anything I missed. I ask to clarify is this for claims from the last year, or claims going forward, and she gets a little defensive and doesn't really answer the question. I quickly back off and say thank you, for fear of rubbing my auditor the wrong way.

I have always wondered why at our podiatry education seminars, in podiatry school, and in residency we don't focus more on audit survival. To me this is one of the most important things we should be aware of. In my residency they taught us to fear medicare big time, and since then I have spent a ton of time and money trying to be prepared. I stand out from the typical podiatrist because I see only about 10-12 patients per day. I spend more than average time with each, and very often I use a 25 modifier as I treat more than just nails and calluses. At least in my case they more often than not have other pathologies at the same time, such as tinea, maceration, skin lesions for biopsy, ulcers, etc. It would be malpractice to ignore these things, yet if you treat them you have a target on your back with medicare. As I understand it Medicare keeps records of how my billing and coding differs from others in my specialty, and if I am an outlier, they don't like it. Since I know this, I chart with photos and extensive documentation, and keep money on the side to defend myself when they come.

I attended a seminar recently where Allen Jacobs encouraged us to not fear the "medicare police" and be real doctors, and treat more than just toenails and calluses. For me he's preaching to the choir, but medicare doesn't like it...
Big names in podiatry like Paul Kesselman? My single malt scotch just exited my nose like a hurricane from laughter.
 
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Big names in podiatry like Paul Kesselman? My single malt scotch just exited my nose like a hurricane from laughter.
It's not even 8am! Oh wait, you're three hours ahead...
 
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It's not even 8am! Oh wait, you're three hours ahead...
I see no relevance to your comments. It’s later afternoon SOMEWHERE.

At least it was after my 6 am road bike trek this morning. Just missed getting clipped by some deer that completely ignored the fact the I had the right of way.
 
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Just missed getting clipped by some deer that completely ignored the fact the I had the right of way.
The deer might've had a scotch or two this morning...

Slainte!
 
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