California Podiatric Physician Jan/Feb/March 2014

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PRESIDENT’S MESSAGE Friends, It has been a long 5 years, and we cannot let our “optional” status stand. We have been scanning the horizon for the best opportunity to have our specialty restored under Medi-Cal. Our time has come.

CPMA is working with our elected leaders in Sacramento to bring forward legislation that will reinstate us in Medi-Cal. Our time has come because everyone knows that it is critical that all Californians, especially the most vulnerable among us, have access to quality medical care by the right provider at the right time. This goal cannot be met without the limb saving services of podiatric physicians and surgeons. Our story is compelling as it is consistent with everything legislators themselves are saying about what is needed in healthcare, such as increased quality, increased access, and cost

containment related to healthcare issues, for example, the prevention of the complications related to chronic diseases like diabetes and obesity.

Our colleagues at the California Medical Association (CMA) are also concerned that MediCal patients are experiencing difficulties obtaining the care they need and have written a letter of support for our federal legislation to define podiatrists as physicians for the purposes of Medi-Cal to improve access to essential foot and ankle care.

See PRESIDENT’S MESSAGE on Page 7

The Western: The Happiest Place for Education The 2014 Western Foot and Ankle Conference is the must-attend continuing education meeting and exhibition for foot and ankle specialists from all over the United States and abroad. Known informally by repeat attendees as The Western, the annual convention sponsored by the California Podiatric Medical Association has become a tradition for members of the podiatric health care community. Hosted by the freshly renovated Disneyland Hotel and Convention Center in Anaheim, California, June 19 - 22, the destination seminar is ideal for Doctors of Podiatric Medicine and Podiatric Medical Assistants to earn the required continuing education contact hours (CECH), including radiology CECH, for their medical license renewals while interacting with colleagues and engaging over 150 vendors exhibiting innovative products and services. Attendees also enjoy the company of their families and friends at this popular resort location.

See The Western on Page 7

- In This Issue Profit Pools 4 Targeting J H , DPM, MBA on

ultman

You Know What Your 11 DoEmployees Would Say?

One Voice 12 2013 Pictorials

16 On Your Toes

Tina Del Buono, PMAC, XT J a n ua r y | F e b r ua r y | m a r c h | 2014

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Contact PICA for more information on medical professional liability insurance or to request a quote.

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You’ve Got Mail CPMA is increasingly utilizing Email and the Association’s website (CalPMA.org) to get important information to members in a rapid, efficient and cost-effective manner.

To make sure that CPMA has your correct email please go to CalPMA.org and log-in.

Once you are logged in, click on Physicians’ Desk and then on Member Directory. Put in your name and view your contact information. If the Association does not have your email, or if it or any of your information is incorrect call 800-794-8988 or email jsteed@calpma.org.

Members are also encouraged to check the CPMA website regularly.

Time is Running Out!

Don’t miss important information that impacts your patients, practice and profession!

ICD-10

Ready?

Are You

Get your vital ICD-10 checkup at the 2014 Western Foot and Ankle Conference (The Western), June 19 - 22 at the Disneyland Hotel in Anaheim, CA. Western coding experts will help you find out where you are, learn where you should be, and give you the necessary information you need to be prepared for the critical October 1, 2014 ICD -10 Implementation date.

2014 Western Foot and Ankle Conference | June 19 - 22, 2014 J a n ua r y | F e b r ua r y | m a r c h | 2014

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Targeting Profit Pools In a healthcare environment marked by shrinking profit margins, doctors continue to search for new ways to increase those margins.

When pondering what to change, consider the philosophy of UCLA basketball coach John Wooden: “Although there is no progress without change, not all change is progress.” I think we would all agree that an idea doesn’t automatically lead to progress just because it is new. When considering strategies in the future, it is important to keep in mind that a few old ideas are still relevant to the healthcare market we encounter today.

One strategy based on an “old idea” is the identification and utilization of “profit pools” – a concept that received attention following an article published in the May/June, 1998, issue of the Harvard Business Review (HBR). The article, “Profit Pools: A Fresh Look at Strategy,” was released at the time that physician practice management companies (PPMCs) were failing. One of the reasons most frequently cited for these failures was that PPMC management

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focused almost exclusively on market share rather than profit share.

In 1998, MedPartners, a PPMC that was acquiring and managing medical practices, also acquired Caremark, a drug benefit company.

Following this acquisition, company managers found that while almost two-thirds of MedPartners’ revenue came from its PPMC, this segment of their business accounted for only one-third of their profit. Conversely, while Caremark only accounted for one third of total company revenue, it delivered two-thirds of the profit. As company-wide profit continued to drop, MedPartners divested its PPMC in order to focus on the more profitable drug benefit business. While it may seem that this decision was a “no brainer,” not all such “profit pools” are as easily identified.

U-Haul and Ford Another example cited in the same HBR article furthers our understanding of profit pools. This is the truck rental industry. In the 1990s, this industry was in the midst of a major competitive battle.

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At the time, U-Haul and Ryder were two prominent companies in the industry. U-Haul appeared to be at a distinct disadvantage because it owned an older fleet of trucks, had higher maintenance costs, and charged renters the lowest prices. In spite of these facts, U-Haul was the most profitable company in the industry – with operating margins three times those of the industry average! The reason for this seemingly contradictory performance turned out to be that U-Haul utilized a strategy its competitors had missed – one focused on profit pools. U-Haul had noted that profit margins in truck rentals were low, with customers shopping aggressively for the best daily rate. It makes sense that a typical consumer would look to pay the least possible rent for a specific truck. “Accessories,” it turned out, offered more profit potential. Once customers signed a rental agreement, their inclination to comparison shop ended.

U-Haul recognized that the highest profit margins in its industry could be captured through sales of accessories, such as cardboard wardrobe boxes, and storage fees, rather than in its core truck rental business. Profitability in this accessory business was driven by volume, and sales of these items were far less price-sensitive than truck rental. In order to create the high volume necessary for high margin accessory sales, U-Haul’s strategy was to keep daily rental rates low. This strategy paid off. Conversely, competitors set rental prices higher – their strategy being to maximize returns from the core truck-rental business. As a result of following this flawed strategy of focusing primarily on truck rentals, Ryder eventually found itself unable to successfully compete in 1996, and was forced to exit the consumer truck rental business.

Every industry has similar profit pools. Consider the automobile industry. Here too we see that – similar to the truck rental business – consumers look for the lowest possible initial “sale” price. Again, the original sales revenues offer the lowest profit margins in the business. The greatest profit sources are actually the service and parts departments, where the negotiation of hourly labor rates or cost for parts is almost non-existent. Another profit pool in this industry is the financing department. In fact, there was a time when most of Ford’s profit was driven by financing and leasing – leaving many to wonder what business Ford was actually in. They recognized that to be in the business of financing cars, they first had to be in the car sales business – so, similar to U-Haul, Ford focused on keeping their prices competitive. Today, auto dealerships have found additional profit pools in products such as extended warranty contracts, LoJack theft recovery services, and guaranteed asset protection plans (to pay off loans if cars are stolen). While these add-on products represent “only” 3% of total revenue for a typical company, they account for 20% of their gross profit.

This “profit pool” perspective can be used by medical practitioners when analyzing the value of offering any medical service or of participating in a contract or provider panel. Some profit pools are more difficult to spot than others, but whenever you are strategizing the future of your practice, simple awareness of this concept is likely to lead you to more profitable decisions. How is the J a n ua r y | F e b r ua r y | m a r c h | 2014

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strategy of maximizing profit pools applicable to podiatric medical practices? Let us examine a few possibilities, and then, with a little creativity, you will likely find more as you view your practice through this lens.

Competition The table below, prepared from a survey conducted years ago

by APMA, depicts utilization of four of the more than 300 CPT codes for conditions commonly treated by DPMs. Comparing the percentages of potential patients who are treated by DPMs, MDs, “self,” and others, we see that only a minority of those with foot problems actually see one of the 14,000 podiatric physicians available to treat them. Even if we include the 700,000 “other” physicians available to these patients, it seems clear that the vast majority of those with foot problems see no doctor at all. Instead, they self-treat or just “live with the pain.” Many podiatric physicians view other DPMs and MDs as competitors. The reality is that their biggest competitors are actually the “Dr. Scholls” of the world. Many such companies include the competitive strategy of expanding their boundaries to capture more of the podiatric business, and there is nothing that prevents podiatric physicians from using this same tactic – expanding their boundaries to capture a portion of the foot care “product” business – countering their tactics.

Yes, the Doctor is in: Monday – Wednesday: 7AM to 10 PM

Thursday – Friday: 7 AM to 9 PM

Saturday 8AM to 6 PM

Sunday 9 AM to 5 PM

See TARGETING PROFIT POOLS on Page 9

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PRESIDENT’S MESSAGE from Page 1

We are also working in collaboration with our physician colleagues to protect MICRA (the Medical Injury Compensation Reform Act), which is a series of statutes crafted to ensure that injured patients are fairly compensated, medical liability rates are kept in check, and physicians and clinics can remain in practice treating patients. The law has been targeted by the trial lawyers because it restricts the amount of money they can collect in damage awards. If successful, the trial attorneys’ efforts will cause our malpractice rates to skyrocket. We will stand beside our physician colleagues to protect the practice of medicine in California.

To reinstate podiatry services in Medi-Cal and protect MICRA we will need to utilize the grassroots efforts for which we are so well known. The issues for which we are advocating will affect every DPM and future DPM in the state. Your CPMA board has a cohesive strategy to advantageously position us from every angle and we need you to implement that strategy. It is vital that you attend the Legislative Leadership Conference in Sacramento on

March 5th so that you can educate your legislators about the indispensable services that you provide to your patients every day.

Our coordinated lobbying efforts with CMA will not go unnoticed by legislators. This unprecedented collaboration is the result of our ongoing work together on the Physician and Surgeon Joint Task Force.

I predicated my term as President on the ideal that CPMA is THE Association for every student, resident, and doctor of podiatric medicine in California. From the implementation of the Affordable Care Act to ICD-10, 2014 will prove to be a transformative one for healthcare. None of us can meet the challenges alone. It is only together that we will ensure that the practice of our specialty continues to be rewarding and fulfilling.

This is the day that we have all been waiting for. Together we will reinstate podiatry services in Medi-Cal and we will protect MICRA. We are all in. (See page 38)

The Western from Page 5

Members of the California Podiatric Medical Association, as well as the national organization the American Podiatric Medical Association, flock to this highly esteemed event, receiving reduced rates on registration costs as well as discounts on malpractice insurance renewal premiums with Podiatry Insurance Company of America simply by attending the risk management presentation.

In addition to a first class program for Doctors of Podiatric Medicine, the Podiatric Medical Assistants program at The Western offers education for front and back office including billing and coding updates, office management training, and patient care.

The Western Foot and Ankle Conference is regarded as a national level event and has made a name for itself in the podiatric medical community, ranked among the three largest meetings of its kind in the country. Doctors of Podiatric Medicine can earn 26 continuing education contact hours and radiology units as they enjoy a stellar program boasting the latest and greatest on technologies, techniques, and trends in podiatric medicine, surgery and management. A top notch faculty including medical doctors, legal and billing experts, as well as podiatric physicians will present cutting-edge lectures, diverse and relevant hands-on-workshops, and practice management courses including the latest billing and coding issues, including the upcoming ICD-10 changes.

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Other than invigorating education and outstanding vendor displays, The Western also affords attendees time to relax with family and friends in “The Happiest Place on Earth” – Disneyland.

The Western offers tickets to the Disneyland and California Adventure theme parks at prices specially marked down for conference attendees making The Western not only an exemplary educational seminar, but also a family affair.

For more information call (800) 794-8988 or visit The Western online at www.TheWestern.org.

The 2014 Western Foot and Ankle Conference

June 19 – 22, 2014

Disneyland Hotel and Convention Center Anaheim, CA

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TARGETING PROFIT POOLS from Page 5

Even though the demand for the treatment of foot and ankle problems continues to grow, so too do the number and types of competitors in this arena. There certainly appears to be an opportunity for DPMs to attract a large percentage of the market who self-treat or who live in pain. Two “simple” strategies for doing so are (1) making themselves more available and capable of accommodating the inflexible schedules that are an obstacle for working people attempting to make appointments and (2) seeing patients soon after arrival at their practices – enabling those patients to be on time for work or for their children’s school pick-up.

Availability and short wait times are not just competitive weapons for attracting patients and building patient satisfaction, they also lead to greater profitability.

Accessories and Ancillaries The current success of global foot care product sales can be viewed as an indicator of the demand for foot care services. In fact, sales of these products are expected to more than double over the next three years. Patients can walk into a pharmacy, stand on a machine, and receive a pair of “custom” orthotics that are fabricated “on the spot.” Most of these products and services offered by competitors are not covered by third party payers; they are cash businesses. Many DPMs offer supplies, DME, and other products, but most consider these to be “incidental” business. Is there opportunity here? Similar to U-Haul offering cardboard wardrobe boxes and other accessories and services to facilitate moving, these value-added products and services offer a convenience to patients when available for purchase at their doctors’ offices, and they offer greater assurance of compliance with patient treatment plans.

These products and services also offer potential profit pools for the “bottom line.”

A host of additional ancillary services well-known to most DPMs are offered by hospitals and other “competitors” – services such as: MRI, ambulatory surgery centers, physical therapy, pathology labs, and ESWT. Certainly, for some types of injections, equipment such as ultra sound offers advantages – as do lasers for certain skin and nail problems. Patients who understand the value of these various “accessories” and ancillaries will pay cash for the value that they see when these goods and services are not covered by insurance.

There will certainly be more of these ancillaries and accessories to consider offering as doctors begin to connect the dots along the entire “value chain” related to foot and ankle care.

Comparing the “foot and ankle business” to that of Ford and others, we can see that (1) one must, first, be “in the business” in order to offer the products, accessories, and ancillaries of that business, and (2) these “products” are more profitable when volume is high – which, in medicine, is enhanced by group practice. I have often written of the profit advantages offered by groups and how this is made possible because these practices are more easily able to increase volume while keeping fixed costs stable.

Examining group practices from the profit pool perspective, it becomes evident that an efficient group will be able to increase the size of their profit pools with every patient seen and each service provided. While a practice may have a gross profit margin of 40%, after overhead, the profit margin for any additional patient volume or volume in services, will be more than double that profit figure as long as the practice is able to keep fixed costs stable. Once fixed costs have been covered, the cost of seeing each additional patient amounts only to the cost of supplies for seeing that patient – which may be as little as 5% of the fee. This creates a 95% marginal profit for any “additional” patient and service. This is only one reason why a merger of multiple practices makes sense.

The Bottom 10% A consultant who wants to grow his/her business recognizes that a proven way to accomplish this goal is to eliminate the bottom 10% of that business. S/he might refer these clients out, or s/he might hire another consultant to come into the practice and handle this portion of the business. The bottom 10% of a medical practice may be represented by a poorly paying healthplan, specific low margin services, or patients who could be seen by some type of physician-extender, under the doctor’s supervision. In most cases, the bottom 10% of a practice consumes significantly more than 10% of the doctor and staff’s time. When this business is “eliminated,” the time previously spent attending to it can be redirected to more productive uses – such as allowing the doctor more time to listen to patients’ secondary complaints – something often ignored because the doctor is in a rush. This should help “grow” a practice in a direction that creates greater value for patients and less aggravation for doctor and staff.

As you can see, there are multiple profit pools available to practices – many of which can be leveraged by the greater volume of a group practice. Identifying and pursuing these pools offers an alternative to doing “more and more” for “less and less.”

Find Us on Facebook Like our Page: www.facebook.com/calpma Join or Group (CPMA Members Only): www.facebook.com/groups/calpma J a n ua r y | F e b r ua r y | m a r c h | 2014

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Do You Know What Your Employees Would Say? Have you ever been to a place of business where you could distinctively tell that an employee was unhappy? Recently while visiting my own doctor I had an interesting experience. The medical assistant asked me to come back to the treatment room, and I noticed that she was not as friendly as I had expected.

As a physician business owner, ask yourself the following questions:

When asked to step on the scale I made a little joke, but there was no smile from her or even a glance my way. Once in the treatment room with the door closed I asked her how her day was going, and she had no problem letting me know how unhappy she was that day. Apparently she usually does another position in the practice, but because of staff illness she had to step in to help the back office.

(2) Does the practice have good delivery systems in place that will ensure that promises and commitments made to the patients are met?

I could somewhat understand her being a little upset, as it is difficult when the office is short staffed, but she did not stop there. She began talking about the organization as a whole and the problems that they were having. She liked the doctor she was working for; she just did not like the management of the practice by the organization that owned them.

I have to say that I learned more about the operations of the practice, and those who worked there, than this assistant learned about why I was there to see my doctor.

As the business owner of your practice have you ever wondered what your employees would say if they are asked, “What do you do for a living?” Or “how do you like working at Dr. Wonderful’s practice?” Do you know how they would answer? Are they excited about what they do, and for whom they do it?

Keeping employees actively engaged and happy at work can be a challenge. Do you know if your employees enjoy what they do? Have you ever taken the time to ask them? If they do not enjoy working at your practice, should they still be working there? Without a doubt, your patients will know if an employee is happy or not.

Have you ever asked your employees what they like most about their job and why? Do you know if they are interested in learning more about the practice and if they would like to get additional training? Have you asked them if there is something you can do to make their job more meaningful to them?

By asking your employees questions like these, you not only will be showing them that you do care about them as people, but also that you want to make their jobs better for them.

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(1) Does the practice provide high quality service and goods that my employees can be proud to recommend with confidence?

(3) Does the practice have excellent business practices - honest, straightforward and carried out with integrity?

(4) Does your practice have clear documentation for patients so that they fully understand the services or products that they are receiving and the cost that may be owed by them?

(5) Does everyone in your practice treat patients, vendors, and each other with the utmost respect?

(6) Do you as a business owner keep an open mind? The leader of any organization must be open to new ideas. Ask for feedback from your staff and patients on how your office is doing, and it will continue to grow.

In the research study, “Does Business Ethics Pay?” by The Institute of Business Ethics (IBE), it was found that companies displaying a “clear commitment to ethical conduct” consistently outperformed companies that do not display ethical conduct.

The Director of IBE, Philippa Foster Black, stated, “Not only is ethical behavior in business life the right thing to do in principle, we have shown that it pays off in financial returns.” These findings deserve to be considered as an important insight for companies striving for long-term success and growth.

Employees want to be connected with a company that they can be proud of. If you can answer yes to the questions above, then with some good team building skills and communication with your employees, you should be able to create an excellent work environment where you and your employees will enjoy working for a long time.

If you cannot answer yes to the questions, do some homework and fix what is broken - you and your employees’ livelihood depends on it.

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southern California

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The Los Angeles County Podiatric Medical Society (LCPMS) held its 6th Annual “One Voice” event on September 21, 2013 at the ultra-chic Peninsula Hotel in Beverly Hills. Dining, dancing and entertainment were share with spouses, friends and colleagues. Most importantly the 2013 event raised over $14,000 for CalPPAC to help ensure that the voice of podiatric medicine is heard when and where necessary.

This year’s event was supported by: Arthrex, Bako, Bauerfeind, IV League, Pacific Vascular International Services and Rad Alliance.

“Please remember to give your support those who support and believe in us,” Derick, Ball, DPM, Chair, CalPPAC

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The Santa Clara Valley Podiatric Medical Society celebrated its 2nd Annual “One Voice” event on October 5 at the 4th Street Summit Center in San Jose. Attendees enjoyed fine food, dancing to the big band rhythms of a live band, and games of chance.

In only its second year, the Northern California One Voice event raised over $12,000 for CalPPAC. The Santa Clara Valley Podiatric Medical Society wishes to thank the following event sponsors for their outstanding support: Platinum Bako, Bioventus, Stryker

Gold BME, Covidien EV3, Integra

Silver Arthrosurface, Dermatran, Pam Labs, Shire Bronze Arteriocyte, Footwear Etc., Guardian Berkshire, Insight Imaging Please remember to support those who go the extra mile to support YOU!” Thomas Elardo, DPM, J a n ua r y | F e b r ua r y | m a r c h | 2014

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on your toes CPMA Sponsors Legislation to Reinstate Podiatric Medicine in Medi-Cal Assemblyman Jimmy Gomez (D-51 District) has introduced legislation (AB 1868) that would “cover medical and surgical services provided by a doctor of podiatric medicine that, if provided by a physician, would be considered physician services, and which services may be provided by either a physician or a podiatrist in the state.” See Summary of bill on page 38.

Be Aware of Changes to Medicare Incentive Programs for 2014 Medicare incentive programs have changed for 2014.

CPMA members need to be aware of several important changes to the Medicare incentive programs for 2014: • The e-prescribing program for CMS has ended. Do not submit the G8553 code on claims in 2014, as the claim will probably be rejected if this code is included.

• If you are submitting PQRS codes for 2014, be aware of the following: • Measures 126 (G8404) and 127 (G8410) are no longer able to be submitted by the individual claims method. If you submit these on individual claims, they will be rejected. If you submit through a CMS-approved registry, these measures can be submitted by the registry method.

• Measure 163 (Diabetic Foot Exam) has changed. Previously, you needed to do one of the three elements-visual inspection, pedal pulses, or monofilament exam. Now you must do all three elements. Also, to report that you successfully did the exam, you report G9226, not 2028F. Reporting 2028F may result in claim rejections.

• The requirements for achieving the PQRS incentive payment (0.5 percent) and avoiding the PQRS penalty in 2016 have changed. See a list of PQRS FAQs and the 2014 fact sheet for more information.

CMS Extends Deadlines for Attesting for Meaningful Use in EHR Incentive Program The Centers for Medicare and Medicaid Services (CMS) has extended the 2013 meaningful use attestation deadline for the Medicare Electronic Health Record (EHR) Incentive Program from February 28 to March 31. However, the criteria still must have been met by Dec. 31, 2013, the end of the reporting period, to qualify for the incentive payments. The deadline extension applies only to the Medicare incentive program, and does not apply to the state Medicaid incentive programs or the Medicare Physician Quality Reporting System.

The deadline was extended because the attestation system has been experiencing a number of technical problems that have prevented some doctors from submitting their attestation data.

CMS has provided the following tips = on attesting: • Before you begin, ensure that your payment assignment and other relevant information is up to date in the Medicare payment system (PECOS).

• Make sure to include a valid email address in your EHR program registration.

• Consider logging on to use the attestation system during non-peak hours such as evenings and weekends.

• Log on to the registration and attestation system now and ensure that your information is up to date and begin entering your 2013 data. (www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/ RegistrationandAttestation.html) • If you experience attestation problems, call the CMS EHR Information Center for assistance.

• If your organization has more than 1,000 providers assigned to a proxy user, use the PECOS system to designate additional proxies to facilitate attestation.

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The CMS EHR Information Center can be reached at (888) 734-6433 and is open Monday through Friday from 7:30 a.m. - 6:30 p.m. (Central Time), except federal holidays.

size or scope. She said the inevitable result of transitioning so many people will be that some will fail to receive the same level of care they’re getting now or they will fail to have that care paid for.

For more information, visit the CMS registration and attestation page.

“I’ve worked in managed care for 20 years, and I’ve seen instances where people move into new health plans and suddenly they can’t see the same doctor or get the same care,” said Wrubel, whose practice is in Hawthorne, Los Angeles County.

https://www.cms.gov/Regulations-and-Guidance/Legislation/ EHRIncentivePrograms/RegistrationandAttestation.html California Alters Rollout of Duals Project, Again State health officials have announced more changes to the April 1 launch of the duals demonstration project in California.

The pilot program to coordinate care for the estimated one million Californians dually eligible for Medicare and Medi-Cal benefits will initially target roughly 400,000 people in seven counties. The first step is to automatically move dual eligibles into managed care plans -- a process known as passive enrollment.

An eighth county, Orange County, was part of the original rollout plans but CMS officials recently deemed the CalOptima health plan was not prepared to handle the Medicare side of the transition and it will likely be excluded from the duals project until at least January, 2015, state officials said. CalOptima was the only insurer lined up for the duals pilot in Orange County.

CMS also found fault with LA Care, one of two health plans participating in the duals project in Los Angeles. LA Care is not prohibited from participation but federal officials will not allow it to passively enroll beneficiaries until January, 2015.

That restriction prompted one of the announced changes, which included: • Three Los Angeles-area health plans were added to enroll people in Cal MediConnect. That takes up the slack from the inability of LA Care to passively enroll duals until 2015, though LA Care will continue to enroll people who choose to join that plan. Three new health plans join HealthNet as insurers in the duals project in Los Angeles County -- CareMore, Care 1st and Molina Healthcare.

• In L.A. County, passive enrollment will start no sooner than July 2014.

• In three other counties, due to 60-day notices going out later than expected, enrollment in April will be strictly voluntary. And passive enrollment in those areas -- Riverside, San Bernardino and San Diego counties -- won’t start until May 1 at the earliest.

There have been some issues in other counties, as well. In Alameda County passive enrollment will be delayed because of financial issues, and passive enrollment in Santa Clara County is delayed by technical glitches.

That leaves a single county -- San Mateo County -- that will begin passive enrollment as originally planned starting Apr. 1.

Concerns About April Implementation CPMA Immediate Past President Dr. Karen Wrubel said the initial launch targeting almost half of the state’s one million duals doesn’t seem much like a pilot project. She pointed out that none of the 14 other states in the national demonstration project are of similar J a n ua r y | F e b r ua r y | m a r c h | 2014

With this high need, often cognitively impaired population gaps in coverage or payment can be dire, Wrubel said.

“We just see patients being confused and overwhelmed. No one seems to know what’s happening, even DHCS. Managed care can be an appropriate choice, but when they’re being enrolled with their passive consent, they have no way of knowing how to navigate the system,” she said.

Wrubel is concerned that many of the beneficiaries won’t know what’s happening to their coverage and will likely just show up in their providers’ facility and want to know why they can’t see that particular provider anymore.

“All of these people being switched at once, it’s going to harm people,” Wrubel said. “They show up at the doctor’s office and they can’t be seen. So they say, ‘Why can’t you see me?’ or ‘Why can’t you get paid?’”

She said that happens on a relatively regular basis in her practice.

“This has happened over the years. We just expect it will happen more now,” Wrubel said.

Wrubel has three main concerns: • LA Care, the largest health plan participating in Los Angeles County, has been excluded by federal officials from passively enrolling dual-eligibles. LA Care had a quality rating that dipped below CMS standards. So now that passive enrollment slack will be taken up by three other plans -- CareMore, Care 1st and Molina Healthcare. “We haven’t met with any of these plans or gone through the vetting process for any of them,” Wrubel said. “LA Care is certainly the largest. How can they not pass the readiness review, but these others can? That makes no sense.” If adding three new health plans increases choice, Wrubel asked, “Then why wasn’t that the case in the beginning?”

• Because of the many delays -- some ordered by federal officials -the transition has many start dates, further muddying the waters for beneficiaries, Wrubel said.

• The biggest issue, Wrubel said, is the process for beneficiaries to opt out of the project. CMS requires that dual-eligibles in the California demonstration have the right to remain in the current fee-for-service system and not participate in the managed care project. DHCS officials discussed either an opt-out form or an opt-out box on other forms, but instead the state will issue a form outlining beneficiaries’ choices. Wrubel and other advocates are worried the form will not adequately explain the opt-out option.

David Gorn, California Healthline 2-5-2014 See ON YOUR TOES on Page 19

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legislation from page 17

The current implementation dates are listed on the following page (current as of 2/7/14).

County Plan(s)

Voluntary Enrollment Passive Enrollment Period Begins Begins (no sooner (no sooner than) than)

Alameda April 1, 2014

July 1, 2014

Alameda Alliance for Health Anthem Blue Cross HealthNet

July 1, 2014

LA Care

(HealthNet)

Los Angeles CareMore April 1, 2014

Dec 1, 2014 (LA Care)

Care 1st CareMore, Care 1st Molina and Molina TBD Orange CalOptima n/a

Inland Empire Health Plan

Delayed Indefinitely

Riverside April 1, 2014 May 1, 2014 Molina

before interest accrues. The letter will be on Noridian letterhead but this is a CMS decision. - Tony Poggio, DPM Ten Tips for Covered California Doctors in 2014 California’s health benefit exchange, Covered California, is now in full swing. As of January 14, Covered California reports that 625,564 individuals have enrolled, accounting for nearly a quarter of all exchange enrollments nationwide.

For those unfamiliar, Covered California is not itself an insurer.

Rather, it is an online marketplace for health insurance products, where individuals can purchase health insurance products that qualify for the federal premium subsidies. Because Covered California is a marketplace, products offered through it should generally be thought of as commercial health insurance products as opposed to “public” coverage, like Medi-Cal, where there is a set fee schedule.

Covered California, however, has also taken on the role of active purchaser, meaning that it will behave much like a large employer negotiating coverage terms (e.g., premiums and patient cost-sharing) on behalf of its employees. This, coupled with requirements in federal and state law, has led to a number of important considerations for physicians when contracting with an exchange plan.

San Bernardino April 1, 2014 May 1, 2014

Whether your practice is participating or nonparticipating with one or more exchange plans, here are 10 pointers as Covered California takes root in 2014:

Molina

1. Verify your participation status and information.

Care 1st

Inland Empire Health Plan

San Diego April 1, 2014 May 1, 2014 Community Health Group HealthNet Molina San Mateo

n/a April 1, 2014

2. Review any contracts or contractual amendments for exchange participation.

Health Plan of San Mateo Anthem Blue Cross Santa Clara April 1, 2014

Due to numerous errors Covered California has taken its consolidated provider directory offline. Currently the directory is not expected to be back online until fall, which means that providers will need to contact the individual plans to determine their status. CPMA has put together a directory of the current exchange plans, which is available in ACA/Covered California Resource Center on the CPMA website CALPMA.org

Dec 1, 2014

Santa Clara Family Health Plan

For more information on the duals demonstration project, visit www.calduals.org and CPMA’s Duals Resource Center at CalPMA.org.

“Overpayment” of the ERx Incentive Program Dear CPMA Members: You may be receiving a letter requesting money back for an “overpayment” of the ERx incentive program. This should pertain to Year 2011. According to CMS you can not receive an ERx incentive payment as well as a EHR incentive payment for the same year.

Therefore they are now requesting back the lesser dollar amount of the two. Be aware that there is a VERY tight window for repayment

If you are participating in Covered California, it may be helpful to undertake a review of any exchange-specific contract provisions, such as exchange-specific rates and policy manuals that may be incorporated by reference. If questions arise, contact the plan-specific contact listed in the plan directory

3. Be aware of the off-exchange products that utilize exchange plan networks.

Every plan offered in the exchange must also be offered outside of the exchange, using the same network. This has resulted in a number of practices unknowingly seeing patients outof-network for commercial products that use an exchange network, as these ID cards will not have the Covered California logo on them. For instance, a Blue Shield card may read “individual PPO” in the upper right and list “enhanced PPO” as See ON YOUR TOES on Page 21

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the product, but only upon further investigation will it show the network as “IFP off exchange,” which is an exchange network.

4. Know who can help patients get more information on exchange plan eligibility and enrollment.

“For practices getting exchange enrollment questions that they are unprepared to answer, printing out a list of nearby certified enrollment assisters may be helpful. These can be found on the Covered California enrollment assistance website “Find Help Near You” https://www.coveredca.com/enrollment-assistance/

9. Let no envelope from a health insurer go unopened too long.

Exchange plans are continually developing critical details as to how these plans will operate, especially in the areas of claims and billing. Many of these details are likely to come via policy manual amendments, which could be in a small envelope or email that is easy to overlook.

10. Stay current on significant developments of Covered California that may impact your practice.

5. Assess your practice’s policies on extending credit to and collections from patients.

For more information visit CoveredCa.org and CPMA’s Exchange Resources at CalPMA.org

Some exchange plans will impose high cost-sharing burdens on patients. Furthermore, the currently evolving situation of the first month’s premium due date and delays in enrollee welcome packets may make eligibility verification difficult for some patients. Practices should consider their strategies for protecting themselves against such potential financial risks.

6. Be prepared for exchange patients in grace period coverage limbo.

Exchange enrollees receiving subsidies, currently 85 percent of those in Covered California, will be allowed three months of premium delinquency before being terminated for non-payment.

If a practice renders services to these patients in the latter two months of the three-month grace period, the plan has the option to suspend payment on those claims and deny them if the patient is terminated for non-payment. California will require exchange plans to represent coverage as inactive for those patients in months two and three of the grace period and give notice to certain physicians of record as to the patient’s status.

Practices should have a policy in place for when they encounter patients in this period of uncertain coverage. Please refer to CPMA’s Podiatric Medicine-The Affordable Care Act-Covered California available in the ACA/Covered California Resources on the Members’ only area of the CPMA website calpma.org

7. Know the participation status of physicians, facilities, and other providers that you refer to or use on a regular basis.

Covered California plans will require that physicians provide advance notice to patients if they are being referred to an outof-network provider or an out of network provider is included in their treatment plan. If, however, the provider shows as participating in the plan’s directory, the practice cannot be held liable for the inclusion.

Stay up to date with exchange developments impacting doctors by checking the CPMA website frequently.

New CMS 1500 Claim Form to Replace Old Version April 1 If you use the CMS 1500 claim form-whether the paper form or a data-entry version in your practice management system-now’s the time to make sure you have the latest version, announced in the summer. Beginning April 1, payers no longer will accept the older version of the form for payment.

This updated claim form, known as “version 02/12,” includes revisions that should improve the accuracy of the data included, accommodating reporting needs tied to current standards for electronic health care transaction and the new ICD-10 code set.

The revised form adds the following functionality: • Indicators for differentiating between ICD-9 and ICD-10 diagnosis codes.

• Expansion of the number of possible diagnosis codes to 12.

• Qualifiers to identify the following provider roles (on item 17): • Ordering • Referring • Supervising Experts say there are five steps your practice should take now to prepare for the switch: 1. If you use a paper form, obtain the revised form from your supplier.

2. If you use a digital version, contact your practice management system vendor to coordinate your software upgrade.

3. Determine when the payers and other trading partners, such as clearinghouses, will begin accepting the revised form.

8. Be aware of the patient cost-sharing across exchange plans.

4. Conduct testing with your trading partners.

Covered California will expect participating plans to encourage physicians to consider patient cost sharing when developing a treatment plan. Furthermore, physicians should consider that high out of pocket costs for things like brand name drugs, imaging and specialty care could impact treatment compliance.

More information may be found in the Covered California benefit summary on the ACA/Covered California Resources page of CalPMA.org

5 Monitor how your claims are being processed using the new form so you can identify any possible issues.

J a n ua r y | F e b r ua r y | m a r c h | 2014

Resources are available online from the National Uniform Claim Committee (http://www.nucc.org), which is charged with maintaining the CMS 1500 claim form.

(AMA Wire 2/12/2014) See ON YOUR TOES on Page 23

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Noridian Transition Issues Updates Dear CPMA Members: Thank you for your patience as we are trying to work through various issues with Noridian. I have some updates and information for you to be aware of. Hopefully we will have more answers within the next week or so.

Routine Foot Care: The root problem was that the routine foot care LCD was retired by Palmetto but they did not transfer the edits that allowed those claims to continue to be paid to Noridian. Hence many routine foot care claims were incorrectly denied. Correcting the edits has been more of a problem than anticipated. New codes needed to be added and they wanted to make sure everything was correct before proceeding. Therefore, the mass adjustment to pay off those old claims has not yet been implemented. They are working on it and hopefully we will have more information in the next week or so.

X-rays: Some x-rays in the past had been denied stating that the preferring provider and/or performing physician information was not listed on the claim form. Some claims were found to have the information listed but Noridian could not translate the information into their system. If you have outstanding x-rays claims (and any other claim for that matter) that have not been paid please contact the provider line and find out what the problem may be. They are quite helpful compared to other carriers in the past. This accomplishes two things: One, hopefully you get an answer and can correct the problem; Two, this records the potential problem within their system such that we call there is a tracking system in place for these claims when you make an inquiry and they can be tracked further. Please forward a few x-ray claims that have not been paid due to “missing referring and/or performing provider information” to CPMA AFTER you have called the provider line.

Billing Order/Multiple ICD-9 Codes: When billing a service that requires a secondary condition such as routine foot care, bill the diagnosis that is payable first (e.g. nail or callus) and the qualifying diagnosis second (e.g. PVD, neuropathy, etc.). However, when billing a condition such as a bunion, there is no requirement to list other subsequent diagnosis such as pain or arthritis (unless specifically required to do so for certain conditions). If you do list other related conditions, make sure the appropriate code for the treatment of the bunion is in the first position.

Modifier Order: If you need to use multiple modifiers use the 59 modifier first, and then add the other modifiers such as RT/LT or the Q modifiers. The rule is to use CPT modifiers first (see front of the CPT book, not all modifiers are “CPT” modifiers!!!) and the list any other modifiers in the second position (RT/LT T).

Sequestration:The two-year compromise proposed budget deal announced by Sen. Patty Murray (D-Wash) and Rep. Paul Ryan (R- Wis) on Tuesday, December 10 would extend the current sequester cuts an additional two years.

50 Modifier: When billing a bilateral procedure and using the 50 modifier. Bill one line only (e.g. 28296-50), use units “one “in box 24G and list the price for the one unit. The computer will calculate the 150% allowance.

J a n ua r y | F e b r ua r y | m a r c h | 2014

Skin Substitutes: Some skin substitutes are being denied inappropriately. System corrections have been requested and a mass adjustment will be issued. The time frame unclear for the various corrections until the extent of the problem is investigated. Will keep you posted.

Cam Walkers: Still no formal answer on this issue. We are trying!!

New posting at Noridian Website : Physical Therapy https://med.noridianmedicare.com/web/jeb/article-detail/-/ view/10525/therapy-cap-recovery-auditor-ra-documentationaddress-california-only Therapy CAP Recovery Auditor (RA) Documentation Address - California Only CMS has instructed Medicare Administrative Contractors (MACs) to submit Automated Development System (ADS) letters for all providers submitting Medicare claims above the established $3,700 threshold for Physical Therapy (PT)/Speech Language Pathology (SLP) and Occupational Therapy (OT) services.

This applies to any provider that is identified as a Prepayment Review Demonstration State (included below). This message is to inform the provider community that the documentation shall be submitted to the Recovery Auditor (RA), Health Data Insights (HDI).

ADS letters will be submitted to any provider that is billing with a Provider Transaction Access Number (PTAN) reflecting a Prepayment Review Demonstration State: California, Florida, Illinois, Louisiana, Michigan, Missouri, New York, North Carolina, Ohio, Pennsylvania and Texas.

Request for further information will come from: Health Data Insights, INC

Tony Poggio, DPM

The CMS Looks to Overhaul the Bidding and Reimbursement Process for Durable Medical Equipment The federal agency is seeking public comment on the methodology it would use to adjust payment amounts. It also wants ideas for potentially simplifying the payment rules while at the same time enhancing beneficiary access to items and services.

Traditionally, Medicare pays for durable medical equipment using a fee schedule that is based on what suppliers charged for the items and services during the 1980s and increased by annual update factors. However, this method has led to steadily rising prices. In fiscal year 2011, the latest year for which prices are available, benefit payments for durable medical equipment were $8.5 billion.

The Patient Protection and Affordable Care Act mandated an adjustment to the fees being paid for durable medical equipment beginning Jan. 1, 2016.

Specific questions the federal agency wants feedback on include whether the cost of items should vary based on the size of the market served. Another is whether it should consider simplifying payment rules by making one monthly payment to the supplier for all related items and services needed each month versus the product by product model in place now. The deadline to submit comments is March 28.

SeeON YOUR TOES on Page 25

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Bundling payments for all items and services into one monthly payment would greatly simplify the reimbursement program for durable equipment, improve beneficiary access to quality items and services, and contribute to greater savings, according to the CMS. Virgil Dickson, Modern Healthcare, 2/24/2014 Correct Coding – Definitions Used for Off-the-Shelf, Custom Fitted and Custom Fabricated Orthotics (Braces) Joint DME MAC Publication As part of the January 2014 HCPCS update codes were created describing certain off-the-shelf (OTS) orthotics. Some of these OTS codes parallel codes for custom fitted versions of the same items.

Refer to the table at the end of this article for a listing of codes.

When providing these items suppliers must: • Provide the product that is specified by the ordering physician, i.e. (1) type of orthosis and (2) method of fitting and/or fabrication (OTS, custom fitted or custom fabricated).

• Be sure that the medical record justifies the need for the type of product (prefabricated versus custom fabricated) • Have detailed documentation in your records that justifies the code selected (e.g., fabrication methods and materials used, appropriate level of fitting and credentials of the individual fabricating and fitting the item).

The following definitions will be used for correct coding of these items.

Off-the-shelf (OTS) orthotics are: • Items that are prefabricated.

• Items that require minimal self-adjustment for fitting at the time of delivery for appropriate use by the beneficiary. This fitting does not require the expertise of a qualified practitioner (see definition below).

Custom fabricated orthotics are: • Items that are uniquely made for an individual beneficiary. No other beneficiary would be able to use this specific item.

• Items that are individually made from basic raw materials including, but not limited to, plastic, metal, leather or cloth in the form of uncut or unshaped sheets, bars, or other basic forms and involves substantial work such as vacuum forming, cutting, bending, molding, sewing, drilling, and finishing prior to fitting on the beneficiary.

• Items that must be individually fabricated over a positive model of the beneficiary. A positive model may be created using various methods e.g., traditional casting methodologies or using CAD/ CAM or similar technology (not all-inclusive). In all cases, in order to be considered as custom fabricated, the item must be created over an actual physical model of the body part.

• Items that require the expertise of a qualified practitioner (see definition below) to custom-fabricate.

The selection and assembly of prefabricated components does not meet the definition of custom fabricated as set out in 1834(h)(1)(F) of the Act. The fabrication requirements specified above, i.e. using raw materials assembled over a model of the individual beneficiary by a qualified practitioner, are the key determinants for the selection of a custom fabricated HCPCS code. Assembly of the item and/or installation of add-on components and/or the use of some basic materials in fabrication/preparation of the item does not change classification from prefabricated (OTS or custom fitted) to custom fabricated.

Kits are: • A collection of components, materials and parts that require further assembly before delivery of the final product.

The term “minimal self-adjustment” is defined at 42 CFR §414.402 as an adjustment the beneficiary, caretaker for the beneficiary, or supplier of the device can perform and does not require the services of a qualified practitioner. For example, adjustment of straps and closures, bending or trimming for final fit or comfort (not all-inclusive) fall into this category. Provision of a prefabricated item requiring minimal self-adjustment for fitting at delivery is considered as OTS.

Note: Incorporating some basic materials as part of the kit does not change the classification of the orthosis from prefabricated (OTS or custom fitted) to custom fabricated.

Custom fitted orthotics are:

Prefabricated items are:

• Items that are prefabricated.

• Items that require substantial modification for fitting at the time of delivery in order to provide an individualized fit. This fitting does require the expertise of a qualified practitioner (see definition below).

Substantial modification is defined as changes made to achieve an individualized fit of the item that requires the expertise of a qualified practitioner i.e., the item must be trimmed, bent, molded (with or without heat), or otherwise modified resulting in alterations beyond minimal self-adjustment. Provision of a prefabricated item that requires substantial modification at delivery is considered as custom fitted.

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• Packaged and completed from a single source or may be an assemblage of separate components from multiple sources by the supplier.

• Items that are a finished or completed final products fabricated from raw materials and parts by the supplier or at a central fabrication facility • Items that may or may not be supplied as a kit. Assembly of the item and/or installation of add-on components and/or the use of some basic materials in preparation of the item prior to final fitting does not change the classification from prefabricated (OTS or custom fitted) to custom fabricated.

Note: Fabrication methods, other than those described in the custom fabricated definition, do not affect the classification of an orthosis as prefabricated. In addition, the site of fabrication of an See ON YOUR TOES on Page 27

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orthosis (e.g., central fabrication facility vs. supplier’s fabrication lab) does not affect the classification as prefabricated.

classification as custom fitted. Fail either one of these criteria and the item is classified as off-the-shelf.

Qualified Practitioners are:

How to Decide What Code Type for OTS, Custom Fitted or Custom Fabricated

• Licensed physicians.

• Licensed physical or occupational therapists.

• Licensed in orthotics or prosthetics by the state in which the item is supplied when the state requires the licensing of orthotics and prosthetics practitioners.

• In states that do not require licensing of orthotics and prosthetics practitioners, a qualified practitioner must be specifically trained and educated to provide or manage the provision of custom fabricated orthotics, and is certified by the American Board for Certification in Orthotics and Prosthetics, Inc. or by the Board for Orthotist/Prosthetist Certification, or is an individual who has equivalent specialized training in the provision of custom fabricated orthoses.

Made by an individual with experience?

YES

Raw materials and basic parts?

NO

YES Made over a physical positive model?

Fit requires substantial modification?

YES

NO

OTS

YES Custom Fabricated

A summary classification algorithm is included at the end of this document to assist in determinations about the type of product and correct code selection.

Refer to the Contractor Supplier Manual, applicable Local Coverage Determination and related Policy Article for additional information about other coverage, coding and documentation requirements.

For questions about correct coding, contact the PDAC Contact Center at (877) 735-1326 during the hours of 8:30 a.m. to 4:00 p.m.

CT, Monday through Friday, or e-mail the PDAC by completing the DME PDAC Contact Form located on the PDAC website: https://www. dmepdac.com/ Classification Algorithm – Overview of Criteria Determining Proper Coding of Orthotics There are two (2) questions to answer, in order: Question 1: Is the item prefabricated or custom fabricated?

Answer: All three (3) elements on the left side of the algorithm (expertise, raw materials and use of a positive patient model) are required in order for the item to be considered custom fabricated. Fail any one and the item is classified as prefabricated.

Question 2: If the item is prefabricated, is it custom fitted or off-theshelf (OTS)?

Answer: Classification depends on (1) what must be done at final fitting and (2) who must do it. Expertise of a qualified practitioner and substantial modification at the time of delivery qualify the items for J a n ua r y | F e b r ua r y | m a r c h | 2014

Prefabricated

Modification requires expertise?

YES Custom Fitted

HCPCS New Code Table can be found at: https://www.noridianmedicare.com/dme/news/docs/2014/02_feb/ correct_coding_definitions_used_for_off_the_shelf_custom_fitted_ and_custom_fabricated_orthotics_braces.html Noridian Now Rolling Out Next Wave of Medicare Revalidation Requests As mandated by the Affordable Care Act (ACA), Medicare Administrative Contractors (MACs) have been requiring doctors to revalidate their Medicare enrollments. Through March 23, 2015, MACs will continue contacting providers, notifying them of the need to revalidate.

The revalidation requirement is necessitated by new screening criteria called for under the ACA. Newly enrolling and revalidating providers will be placed in one of three screening categories representing the level of risk to the Medicare program. The level of risk will determine the degree of screening to be performed when processing the enrollment application.

Doctors who receive a request for revalidation must respond to that request within 60 days or face the possibility of being See ON YOUR TOES on Page 29

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2013/2014 board of directors President Carolyn E. McAloon, DPM Castro Valley, CA 94546 P: (510) 581-1484 drmcaloon@bayareafootcare.com President-Elect Thomas J. Elardo, DPM Los Gatos, CA 95032 P: (408) 358-6234 painfulfeet1@gmail.com Vice President Ami A. Sheth, DPM Los Gatos, CA 95032 P: (408) 358-6234 amishethdpm@gmail.com Immediate Past President Karen L. Wrubel, DPM Hawthorne, CA 90205 P: (310) 675-0900 drkw@cox.net Secretary-Treasurer Rebecca A. Moellmer, DPM San Bernardino, CA 92404 P: (909) 886-3668 rebeccamoellmer@hotmail.com

Directors John A. Chisholm, DPM 345 F Street, Suite 100 Chula Vista, CA. 91910 P: (619) 427-3481 F: (619) 420-7807 dr_triguy@yahoo.com Devon Glazer, DPM Newport Beach, CA 92660 P: (949) 272-0007 drdev01@yahoo.com Thomas J. Tanaka, DPM Ontario, CA 91761 P: (909) 724-5052 drtanaka@doctor.com Jonathan J. Uy, DPM Hercules, CA 94547 P: (510) 724-4674 flipdpm@sbcglobal.net Mark A. Warford, DPM Fair Oaks, CA 95628 P: (916) 548-0218 markwarforddpm@att.net

Executive Director Jon A. Hultman, DPM 2430 K St Ste 200 Sacramento, CA 95816 P: (916) 448-0248 (800) 794-8988 jhultman@calpma.org jonhultman@gmail.com General Counsel C. Keith Greer, Esq. San Diego, CA 92128 P: (858) 613-6677 greerkeith@aol.com Governmental Representative Jodi Hicks Sacramento, CA 95814

2014 CPMA House of Delegates will convene

Wednesday, June 18, 2014 Disneyland Hotel Anaheim, CA

Parliamentarian/ Recording Secretary Roderick Farley, DPM/ Nedra L. Farley Albuquerque, NM 87122 drrodfarley@gmail.com

Student Representatives Kevin Grenier (CSPM) Oakland CA 94601 Kevin.grenier@samuelmerritt.edu Dayna Chang (Western U) Walnut CA, 91789 changd@westernued.org

2013/2014 COMPONENT SOCIETY PRESIDENTs ALAMEDA/CONTRA COSTA COUNTY Timothy Dutra, DPM P: (510) 869-6511 x7564 tdutra@samuelmerritt.edu docpod85@yahoo.com CENTRAL VALLEY Matthew Takeuchi, DPM Stockton, CA 95204 P: (209) 948-3333 mjtakeuchi@gmail.com COACHELLA VALLEY Harvey Danciger, DPM Palm Desert, CA 92260 P: (760) 568-0108 docofeet@gmail.com INLAND Diane Koshimune, DPM Pomona, CA 91766 P: (909) 706-3778 ISCPMA@gmail.com LOS ANGELES COUNTY Gabriel Halperin, DPM Los Angeles, CA 90063 P: (323) 264-6157 ghalp@earthlink.net MID-STATE Richard Motos, DPM Visalia, CA 93291 P: (559) 734-1171 moetoes@hotmail.com

MONTEREY BAY AREA Vittorio Lagana, DPM Monterey, CA 93940 P: (831) 375-5634 vlagana@gmail.com

SAN FRANCISCO/SAN MATEO Bill Metaxas, DPM San Francisco, CA 94108 P: (415) 433-3668 bjm@faisf.com

NORTHERN CALIFORNIA KAISER Thomas DaSilva, DPM Walnut Creek, CA 94596 P: (925) 295-7099 thomasdasilva@hotmail.com

SAN LUIS OBISPO/SANTA BARBARA David Sterling, DPM Santa Maria, CA 93455 P: (805) 928-5645 sterlingfamily4@gmail.com

ORANGE COUNTY Gregory Eirich, DPM Tustin, CA 9 92780 P: (714) 669-1780 eirichdpm@sbcglobal.net REDWOOD EMPIRE Paul Weiner, DPM Vallejo, CA 94590 P: (707) 643-3687 mdweiner@scrserv.com SACRAMENTO VALLEY Mark Warford, DPM (liaison) Fair Oaks, CA 95825 P: (916) 488-8750 markwarforddpm@att.net SAN DIEGO/IMPERIAL Nicholas DeSantis, DPM San Diego, CA 92101 P: (619) 239-3286 footdoc5@pacbell.net

SANTA CLARA VALLEY Adam Howard, DPM Cupertino, CA 95014 P: (408) 446-5811 footdoc4u@gmail.com SHASTA REGION Gordon Shumate, DPM Redding, CA 96001 P: (530) 246-4800 g.shumate.dpm@frontiernet.net SOUTHERN CALIFORNIA HMO Anthony Cannizzaro, DPM South Pasadena, CA 91031 P: (323) 857-2000) anthony.x.cannizzaro@kp.org doctoracann@aol.com VENTURA COUNTY Heather McGuire, DPM Ventura, CA 93003 P: (805) 648-2016 drhmcguire@me.com

The California Podiatric Physician is the official publication of the California Podiatric Medical Association.

CPMA and the California Podiatric Physician assume no responsibility for the statements, opinions and/ or treatments appearing in the articles under an authors’s name. For editorial or business information and advertising, contact California Podiatric Medical Association, 2430 K Street, Suite 200, Sacramento, California 95816; telephone, (916) 448-0248; facsimile; (916) 448-0258; e-mail; calpma.org.

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TheWestern.Org

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deactivated. Do not do anything until you get a letter instructing you to revalidate. (This is very important to ensure an orderly enrollment process.) Physicians who are making changes (moving, closing practice, etc.) should continue to submit their changes as usual.

For providers in PECOS - the revalidation letter will be sent to the special payments and correspondence addresses simultaneously.

If these are the same, it will also be mailed to the primary practice address.

For providers NOT in PECOS - revalidation letters were sent earlier this year to the special payments or primary practice address. If you are not in PECOS and have not already received a letter, contact Noridian for guidance.

To find out whether you have been mailed a revalidation notice go to the revalidation page on the CMS website . If you are listed, and have not received the request, contact Noridian at (855) 609-9960.

Tony Poggio, DPM eRx HCPCS G8553 Deleted Effective for claims billed with dates of service 01/01/2014, HCPCS G8553 is no longer valid. Because Electronic Prescribing (eRx) reporting is not being monitored during 2014, no new code will be created. The eRx incentive program finalized on 12/31/13; however, providers are encouraged to continue to electronically prescribe as it is a measure under Electronic Health Records (EHR) and should be reported as such.

Individual eligible professionals and group practices who participated in the eRx Group Practice Reporting Option (GPRO) who were not successful electronic prescribers will be subject to a 2.0% payment adjustment on their Medicare Part B services provided January 1, 2014 through December 31, 2014.

To avoid the 2014 eRx payment adjustment, individual eligible professionals and group practices must have been successful 2013 electronic prescribers, reporting HCPCS G8553 on at least 10 billable Medicare Part B Physician Fee Schedule (PFS) services provided from January 1, 2013 through June 30, 2013.

Name Change for the American Board of Podiatric Surgery The American Board of Podiatric Surgery® (ABPS) will adopt the trade name the American Board of Foot and Ankle Surgery (ABFAS), effective July 1, 2014.

The ABPS changed its name to American Board of Foot and Ankle Surgery to clarify the anatomical scope of podiatric surgical certification to the public, insurance industry, and governmental organizations.

The name change will not affect the board certification process. The ABFAS will continue to offer two certificates, Board Certified in Foot Surgery and Board Certified in Reconstructive Rearfoot/Ankle Surgery.

Certificates will reflect the new name. Diplomates requesting a certificate with the new name will be able to obtain one at the current fee for a replacement certificate.

Diplomates will have until June 30, 2017 to implement use of the new name.

J a n ua r y | F e b r ua r y | m a r c h | 2014

Quarterly Results of Widespread Prepayment Review of Claims for Therapeutic Shoes for Persons with Diabetes (HCPCS A5500) Current Review Results The Jurisdiction D DME MAC Medical Review Department is conducting a widespread complex review of HCPCS code A5500. The quarterly edit effectiveness results from September 2013 through December 2013 are as follows: The A5500 review involved 3,741 claims, of which 3,050 were denied. Based on dollars, this resulted in an overall claim potential improper payment rate of 82%.

Primary Documentation Errors that Resulted in Denial of Claims • Documentation of foot abnormalities by certifying physician not met There must be documentation to support that the certifying physician has documented in the patient’s medical record one or more of the following conditions: a. Previous amputation of the other foot, or part of either foot, or b. History of previous foot ulceration of either foot, or c.History of pre-ulcerative calluses of either foot, or d.Peripheral neuropathy with evidence of callus formation of either foot, or e.Foot deformity of either foot, or f.Poor circulation in either foot.

In order to meet criterion 2, the certifying physician must either: a.Personally document one or more of criteria a – f in the medical record of an in-person visit within 6 months prior to delivery of the shoes/inserts and prior to or on the same day as signing the certification statement; or b.Obtain, initial/sign, date (prior to or on the same day as signing the certification statement), and indicate agreement with information from the medical records of an inperson visit with a podiatrist, other M.D. or D.O., physician assistant, nurse practitioner, or clinical nurse specialist that is within 6 months prior to delivery of the shoes/inserts, and that documents one of more of criteria a – f.

Note: The certification statement is not sufficient to meet the requirement for documentation in the medical record.

• Documentation of diabetes management by certifying physician not met There must be documentation to support that the certifying physician has certified that indications (1) and (2) are met and that he/she is treating the patient under a comprehensive plan of care for his/her diabetes and that the patient needs diabetic shoes. For claims with dates of service on or after 1/1/2011, the certifying physician must: a. Have an in-person visit with the patient during which diabetes management is addressed within 6 months prior to delivery of the shoes/inserts; and b.Sign the certification statement (refer to the Documentation Requirements section of the related Local Coverage Determination) on or after the date of the in-person visit and within 3 months prior to delivery of the shoes/inserts.

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Note: Per Policy Article A37076 the Certifying Physician is defined as a doctor of medicine (M.D.) or a doctor of osteopathy (D.O.) who is responsible for diagnosing and treating the patient’s diabetic systemic condition through a comprehensive plan of care. The certifying physician may not be a podiatrist, physician assistant, nurse practitioner, or clinical nurse specialist.

• No documentation was received Suppliers are in violation of Supplier Standard #28 when, upon request, they fail to provide requested documentation to a Medicare contractor. Medicare regulations (42 C.F.R §424.516[f ]) stipulate that a supplier is required to maintain documentation for seven years from the date of service and, upon the request of CMS or a Medicare contractor, provide access to that documentation. Therefore, the consequences of failure to provide records may not only be a claim denial but also referral to the NSC. Please also remember, the documentation must be submitted to our office within 45 days from the date on the ADR letter. Failure to provide the requested documentation within 45 days may result in a partial or complete denial of the claim. Submission information can be found on the ADR letters or under the claims section on our website at https://www.noridianmedicare.com/dme/claims/edi.html • Documentation of in-person visit prior to selection of items not met.

There must be documentation from the supplier to support an in-person visit prior to selection of the item billed. Prior to selecting the specific items that will be provided the supplier must conduct and document an in-person evaluation of the patient. The in-person evaluation of the patient by the supplier at the time of selecting the items that will be provided must include at least the following: a. An examination of the patient’s feet with a description of the abnormalities that will need to be accommodated by the shoes/ inserts/modifications. b. For all shoes, taking measurements of the patient’s feet.

For custom molded shoes (A5501) and inserts (A5513), taking impressions, making casts, or obtaining CAD-CAM images of the patient’s feet that will be used in creating positive models of the feet.

Going Forward Based on the results of this review, Noridian will continue with the Prepayment Widespread Review.

Education Resources It is important for suppliers to be familiar with the documentation requirements and utilization parameters as outlined in the Therapeutic Shoes for Persons with Diabetes Local Coverage Determination (LCD) L157 and Policy Article A37076.

Suppliers can also review specific policy resources for Therapeutic Shoes for Persons with Diabetes on the Noridian website located at https://www.noridianmedicare.com/dme/coverage/resources/ therapeutic_shoes_for_persons_with_diabetes.html. There, you will find information related to proper documentation requirements including a physician letter, documentation checklists, FAQs, and a presentation used during web-based workshops.

J a n ua r y | F e b r ua r y | m a r c h | 2014

Noridian provides educational offerings by scheduling supplier workshops, training opportunities, and presentations. Educational training and events are located at https://www.noridianmedicare. com/dme/train/.

Information about probe/error validation reviews may be found in CMS Publication 100-8, Program Integrity Manual (PIM), Chapter 3 located at http://www.cms.gov/manuals/downloads/pim83c03.pdf This link takes you to an external website..

CMS Announces Stepped-up Efforts to Stop Fraud The Centers for Medicare and Medicaid Services (CMS) announced in January that it would be stepping up efforts to identify and punish “recalcitrant” providers who have been found to be abusing the program and have not changed their inappropriate behavior even after extensive education to address the problem.

According to CMS, recalcitrant providers could face civil fines and expulsion from the Medicare program.

CMS has instructed Medicare contractors to refer such cases to the Department of Health and Human Services (HHS) Office of the Inspector General (OIG), who has the authority to impose civil fines and remove providers from all federal health programs.

CMS estimates that approximately 10 percent of fee-for-service payments or approximately $6 billion a year in costs to the Medicare program are due to fraud.

Medicare contractors have been instructed to focus on two particular kinds of abuse-providers with a pattern of claims for goods and services that are deemed not medically necessary and those who knowingly bill for services in excess of patients’ needs.

According to CMS, the agency will focus on the highest billing providers. There are about 300 providers nationwide who receive more than $3 million yearly from Medicare.

Congress Calls for RAC Reform The Medicare Recovery Audit Contractor (RAC) process needs immediate reform, according to a bipartisan letter to Health and Human Services Secretary Kathleen Sebelius signed by 111 members of the U.S. House of Representatives.

The representatives said in the letter that “CMS should implement reforms to ensure that auditors are charged with identifying real claim coding and medical documentation errors, as well as provide a more transparent mechanism through which providers can be informed of errors so as to avoid them in the future.”

The letter further suggested that Congress and the Centers for Medicare & Medicaid Services (CMS) consider an alternative RAC payment model. The current model pays RACs a commission of between 9 percent and 12.5 percent based on the dollar amount of claims they deny. This payment incentive encourages RACs to deny even correct claims, the letter states.

“In fact, according to a November 2012 OIG [Office of Inspector General] report, 72 percent of hospital Medicare Part A appeals that have reached the third level of the Medicare appeals process are overturned in favor of the hospital,” the letter states.

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When RACs erroneously deny inpatient stays, the letter states, Medicare beneficiaries face higher out-of-pocket expenses under Medicare Part B and in some cases must cover the cost of post-acute care. “This is not the way the Medicare program was intended to operate,” the letter says.

The letter further calls on the CMS to adopt the provisions of the Medicare Audit Improvement Act of 2013, which proposed to limit the amount of documentation RACs can request from hospitals.

“Medicare beneficiaries and those who provide them with care have an important stake in ensuring the RAC auditing process is fair and effective,” the letter states. “We urge you to take immediate action before we see further problems with the RAC auditing program.”

A survey of hospitals last August found medical record requests from RACs had increased 47 percent from 2012’s fourth quarter. In the second quarter of 2013, complex audit denials by RACs increased 58 percent; of these, two-thirds of hospitals named medical necessity denials as the most expensive RAC requests.

Zack Budryk, Fierce Health 2/12/2014 Bills Introduced To Reverse, Study Effects of 10% Cut to Medi-Cal Providers An Assembly bill has been introduced that would reverse the 10% cut in Medi-Cal provider rates approved by the Legislature in 2011.

A second Assembly bill, also introduced yesterday, would take a different tack on the reimbursement conundrum. It would order an independent analysis to determine the degree of impact rates have on access to care in California.

The bill to reinstitute pre-2011 Medi-Cal provider rates is AB 1805

by Assembly member Nancy Skinner (D-Berkeley) with Richard Pan (D-Sacramento) as co-author. The independent analysis of rates’ impact on access is AB 1759, with Pan as lead author and Skinner as co-author.

The provider rate reduction started going into effect in September last year after the law was held up in court for more than two years.

California providers, who already faced some of the lowest Medicaid (Medi-Cal) reimbursement rates in the country before the cuts were approved, will fall even further behind their counterparts in other parts of the country as the cuts are implemented. Medi-Cal is California’s version of the federal Medicaid program.

“The real problem is we have the second-lowest rate of physicians accepting Medi-Cal patients in the nation,” Pan said. The low rate of taking on new patients has already started to create a serious access problem in California, he said.

“Even when Medi-Cal rates have dropped in the past, providers still see their [Medi-Cal] patients, because that’s what providers do, they’re not going to just drop patients,” Pan said. “The problem is, they don’t take up new ones -- and that creates the access problem.”

David Gorn, California Healthline, 2/20/2014 CMS Warns of Fraudulent DME Suppliers At the end of January the Centers for Medicare and Medicaid Services (CMS) sent a to providers asking them to pay attention to 32 |

solicitations they receive from durable medical equipment (DME) suppliers and report any suspicious activity to the U.S. Department of Health and Human Services’ Office of the Inspector General (OIG).

According to CMS, most fraudulent solicitations are obvious in their wording or their attempts to get physicians to approve unnecessary medical equipment and supplies.

These marketing schemes by DME suppliers can include: • Unsolicited orders for medical equipment or supplies, often with wording such as “We received a call from your patient Jane Doe who wants you to order...” and then lists multiple items on a pre-printed order • Advertisements that Medicare will provide you with payment for patient referrals • Pre-completed medical necessity forms with instructions to just “Sign and Date Here” Doctors are urged to: • Pay careful attention to orders that cross your desk asking for your signature. Review the patient’s medical record before signing an order.

• View with a skeptical eye unsolicited orders for patients no longer in your practice or whom you have not seen in a long period of time.

• Document in your patient’s medical record the medical justification for any DME ordered for your patient. You also may want to keep a record of the DME you’ve ordered for your patient, similar to (or part of ) your patient’s medication list.

Suspected abuse may be reported to the OIG at hhstips@oig.hhs. gov, (800) 447-8477 or via fax at (800) 223-2164.

FDA Calls on Doctors to Limit Amount of Acetaminophen in Prescription Painkillers In advance of eliminating the availability of prescription combination drugs that contain more than 325 milligrams of acetaminophen per dosage unit, the U.S. Food and Drug Administration (FDA) has recommended that physicians stop prescribing medications that exceed this limit, citing a risk of liver damage.

Acetaminophen is the leading cause of drug-induced acute liver failure in the United States, and no data exists demonstrating that taking more than 325 milligrams of acetaminophen per dosage provides additional benefits, the FDA said in its recommendation.

Some prescription combination drugs that contain both acetaminophen and another ingredient, such as hydrocodone, have as much as 750 milligrams of acetaminophen per dose and are most commonly prescribed to manage pain from acute injuries and following surgery.

In 2011 the FDA began asking manufacturers to voluntarily limit the amount of acetaminophen in prescription combination drugs to no more than 325 milligrams per dosage by Jan. 14, 2014.

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of severe liver damage, which can result from taking too much acetaminophen,” the statement said.

About half of manufacturers complied with the request.

Prescription drug products that don’t meet the FDA requirement remain on the market temporarily, but the FDA plans to withdraw approval of these noncompliant prescription combination drugs “in the near future.”

In the meantime, the agency recommends doctors prescribe combination drugs that comply with the FDA limit. “A two-tablet or two-capsule dose may still be prescribed, if appropriate,” the FDA said. “In that case, the total dose of acetaminophen would be 650 milligrams (the amount in two 325 milligram dosage units).”

Doctors who prescribe larger doses of acetaminophen can expect calls from pharmacists. The agency recommended that pharmacists who receive a prescription for combination painkillers with more than 325 milligrams of acetaminophen contact the prescriber to discuss switching to a product containing lower doses of acetaminophen.

The FDA said it will address over-the-counter (OTC) acetaminophen products in a separate regulation. Warnings about the potential for liver damage already are required on labels of the hundreds of OTC products containing the drug.

“Many consumers are often unaware that many products (both prescription and OTC) contain acetaminophen, making it easy to take too much,” the agency said.

Questions can be directed to the Division of Drug Information at (888) INFO-FDA or via email druginfo@fda.hhs.gov

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significance in 13 states that currently prohibit labs from releasing test results directly to patients. Current California law allows the release of lab results to patients if providers give approval.

Although under the Health Insurance Portability and Accountability Act (HIPAA), physicians and other covered entities were already required to provide patients with copies of their protected health information (PHI) upon request, many laboratories were exempt from this requirement.

While patients can continue to get access to their lab tests from their physicians, under the new rule, labs will be required to provide patients copies, including electronic copies, of their lab test results within 30 days of a request.

The final rule amends the Clinical Laboratory Improvement Amendments (CLIA) of 1988.

Before the revisions, CLIA stipulated that labs could release test results to only three types of individuals: the person authorized under state law to order or receive results, typically a physician; the person responsible for using the test results for treatment; and a referring lab that requested the test.

(CMANet 1/19/2014) Medical Board to Suspend Licenses of Doctors with Delinquent Delinquent Taxes The Medical Board of California will soon be sending notices to doctros who have outstanding tax obligations, warning that their medical licenses may be suspended if they do not pay their tax obligation or enter into a payment plan within 90 days.

The U.S. Department of Health and Human Services (HHS) will begin releasing information on payments to individual physicians upon request and will publish aggregate data sets about physician pay.

A state law, passed in 2011, authorizes the medical board to deny an application for licensure and to suspend the license of any licensee who has outstanding tax obligations due to the Franchise Tax Board (FTB) or the State Board of Equalization (BOE) and appears on either the FTB or BOE’s certified lists of top 500 tax delinquencies over $100,000.

The planned payment data release followed a 2013 federal judge’s decision to strike down a decades-old ban on releasing Medicare physician data due to privacy concerns. The judge ruled privacy concerns were secondary to the public interest of disclosing payment data. Such data could fuel examinations of Medicare waste and fraud.

Doctors who fail to either pay the taxes owed or enter into a payment installment plan with the relevant agencies will have their licenses denied or suspended until the Medical Board of California receives a release from the FTB or BOE. The form for requesting a release will be included with the preliminary notice of suspension.

HHS officials said the disclosures would come through individual Freedom of Information Act requests for physician pay data.

The agency plans to use a “balancing test” to determine which information should be released, according to a final rule detailing how the disclosures will occur.

Healthcare Financial Management Association 1/14/2014

Suspensions will be posted on the medical board’s website and publicly distributed through its electronic notification system.

(AMA Wire 1/16/2014) CMS to Release Physician Pay Data

HHS Announces New Rule that Gives Patients Direct Access to Lab Test Results Patients will soon be able to obtain their medical test results directly from the laboratory, rather than having to request a copy from their physician’s office, according to a new rule announced Monday by the U.S. Department of Health and Human Services (HHS).

The rule is part of a broader effort to give Americans more control over their health care. It supersedes state law and will have particular J a n ua r y | F e b r ua r y | m a r c h | 2014

The law prohibits the Medical Board of California from refunding any money paid for the issuance or renewal of a license where the license is denied or suspended.

Names of those owing money to that state are published by the FTB and BOE on their websites. Physicians can check if they are currently on the FTB’s or the BOE’s lists. If you believe you are on either list in error, please call the FTB at (866) 418-3702 or the BOE at (916) 445-5167.

For more information visit: https://www.ftb.ca.gov/aboutFTB/Delinquent_Taxpayers.shtml http://www.boe.ca.gov/cgi-bin/deliq.cgi See ON YOUR TOES on Page 34

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CMS Delays Meaningful Use Deadlines CMS announced a new timeline for meaningful use implementation for Medicare and Medicaid EHR Incentive Programs on Friday, December 6.

Providers will be given another year to show that they met Stage 2 criteria. Providers starting in Stage 2 in 2014 will stay in Stage 2 through 2016. Stage 3 will not begin until calendar year 2017 for physicians and other eligible providers who have completed two years of Stage 2. The proposed rule describing Stage 3 requirements is expected to be released next fall.

This much-needed delay is a result of congressional pressure on CMS, emphasizing that the health IT industry was not fully ready for Stage 2 upgrades, which would adversely affect providers’ ability to meet meaningful-use requirements. CMS has implemented the extension of Stage 2 through 2016 to allow for a smoother transition to Stage 3 in 2017. Read more on Health Information Technology in the CPMA Compliance Center at CalPMA.org While this is a welcome reprieve for most practices, this announcement does not change the 2014 requirements for reporting meaningful use to avoid Medicare payment penalties in 2015. Beginning January 1, 2015, Medicare providers who have not successfully attested to meaningful use of an EHR may incur payment penalties, as mandated by the HITECH Act. These payment adjustments are 1-2 percent of total Medicare charges in 2015, to

2 percent in 2016 and 3-5 percent in 2017 and beyond. For more information, click here.

(Source: Modern Healthcare 12/6/2013;CMA 12/10/2013) Ordering and Referring Denial Edits Implemented on January 6, 2014 Are you currently receiving the following error messages on your Remittance Advices (RAs)?

CMS has instructed contractors to turn on Phase 2 denial edits on January 6, 2014, and claims missing necessary referring/ordering physician information will be denied.

• N264 - Missing/incomplete/invalid ordering provider name • N265 - Missing/incomplete/invalid ordering provider primary identifier CMS will instruct contractors to turn on Phase 2 denial edits on January 6, 2014. These edits will check the following claims for a valid individual National Provider Identifier (NPI) and deny the claim when this information is invalid: • Claims from clinical laboratories for ordered tests; *Claims from imaging centers for ordered imaging procedures; *Claims from suppliers of Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) for ordered DMEPOS; and *Claims from Part A Home Health Agencies (HHAs). For more information: • MLN Matters Article SE1305, “Full Implementation of Edits on the Ordering/Referring Providers in Medicare Part B, DME, and

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Part A Home Health Agency (HHA) Claims (Change Requests 6417, 6421, 6696, and 6856)” Source: LEARNRESOURCE-L Email Update, National Institutes of Health, U.S. Department of Health and Human Services dated November 6, 2013 Ordering Referring Report: Suppliers may access the file maintained

by CMS that contains the NPIs and the names of physicians and non-physician practitioners who have current enrollment records in PECOS and are of a type/specialty that is eligible to order and refer.

Claim Submission *Ensure the physicians and non-physician practitioners on accepted orders and referrals have current Medicare enrollment records and are of a type/specialty that is eligible to order or refer in the Medicare program: http://www.cms.gov/Medicare/ Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/ MedicareOrderingandReferring.html • Correctly spell the ordering/referring provider’s name.

• Do not use “nicknames” on the claim.

• Do not enter credentials • Item 17 on Paper Claims: Enter the ordering/referring provider’s name in the following order: First Name, Last Name (e.g., John Smith) *Electronic Claims: The qualifier in the electronic claim, 2310A NM102 loop is a 1.

• Enter the individual NPI and ordering/referring provider name, not the organization.

Claim Processing If the ordering/referring provider: • Is not on the claim, the claim will not be paid.

• Is on the claim, Medicare will verify the ordering/referring provider is in PECOS and eligible to order and refer.

• Is not in PECOS or is in PECOS but is not of the specialty to order or refer, the claim will not be paid.

(Source: Tony Poggio, DPM) Status of MICRA Initiative The proponents of a ballot initiative to raise the MICRA cap on noneconomic damages, often referred to as pain & suffering, from $250,000 to $1,100,000 have begun gathering signatures to put the initiative on the ballot next fall. If the proponents can gather the required 504,760 signatures by March 24, 2014, the measure titled, “Drug and Alcohol Testing of Doctors. Medical Negligence Lawsuits.

Initiative Statute” will be on the November 2014 ballot.

The window dressing of the initiative is the “Pee in a Cup” language which would require, among other things: (1) physicians to submit to drug/alcohol testing, and (2) a presumption of professional negligence by a physician or surgeon who tested positive for drugs/alcohol, or refused to comply (won’t pee in the cup).

Does “Pee in the Cup” Apply to Podiatrists?

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Chapter 5 of Division 2 of the Business & Professions Code. That would seem to exclude podiatrists, however, existing language in Chapter 5 of Division 2 of the Business and Professions Code (§ 2041) reads: “The term “licensee” as used in this chapter means the holder of a physician’s and surgeon’s certificate or doctor of podiatric medicine’s certificate, as the case may be, who is engaged in the professional practice authorized by the certificate under the jurisdiction of the appropriate board.”

If the Initiative were to pass, there might be a question whether podiatrists are subject to the “Pee in a Cup” provision.

Raising the MICRA Cap There is no question, however, that the initiative’s language to increase the cap would apply to podiatrists and all other licensed health care providers and facilities currently covered by the cap.

The damages cap was enacted as part of MICRA in 1975 and is found at Civil Code § 3333.2[1]. Section 3333.2 covers health care providers licensed under the “Healing Arts” Division of the Business and Professions Code (Division 2) which includes Doctors of Podiatric Medicine (Chapter 5, Article 22).

Increasing the MICRA cap through a ballot initiative was threatened earlier this year by the Initiative’s proponents, the socalled Consumer Watchdog - fronting for the Consumer Attorneys of California (CAOC) - if the hike wasn’t done through the normal legislative process. When a bill to increase the MICRA cap was not forthcoming, the initiative process was pursued.

CAOC, often referred to as the trial lawyers, insist they have not taken a position on the Initiative proposal, yet hired three wellconnected lobbying firms to work on the malpractice issue last April.

CAOC reported paying these firms $122,000 through September 30th.

The trial lawyers now want to index[2] the MICRA cap, even though COLAs were rejected on three separate occasions in the past.

When the MICRA legislation was working its way through a special session in 1975[3], the bill’s author[4] was surprised the trial lawyers rejected inclusion of a COLA. The trial lawyers surmised the law without a COLA might make it more likely to be overturned by the Courts . . . which did not happen[5]. In the 1987 tort reform napkin deal, the trial lawyers opted for an increase in their contingency fees rather than an increase in the cap. In 1999, they objected to a COLA from that point in time going forward, rather than retroactive to 1975. They asked then-Speaker Villaraigosa to drop his bill, which had passed the Assembly, as the prospective COLA would be embarrassing to accept.

The MICRA Battle Going Forward Maintaining the MICRA cap at its current level is vital in terms of health care access and costs in California. It also has important national implications as MICRA is seen as the medical malpractice gold standard. Malpractice caps work, as demonstrated here and elsewhere, so if MICRA is weakened reforms in other states would face renewed threats. CPMA is an active participant the coalition See ON YOUR TOES on Page 37

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CENTENNIAL GALA PLANNING COMMITTEE  Tracy L. Basso, DPM ‘88 Andrea Carrick

Samuel Merritt University and the California School of Podiatric Medicine cordially invite you to the

Centennial Gala Celebrating 100 Years of Educating Doctors of Podiatric Medicine

Friday, June 20, 2014

6:00 p.m. Wine and Hors D’oeuvres 7:00 p.m. Dinner, Program and Dancing The Disneyland Hotel 1150 West Magic Way Magic Kingdom Ballroom 1 and 4 Anaheim, California $250 per person*

(Sponsorship Opportunities Also Available)

For more information or to purchase tickets online go to http://www.samuelmerritt.edu/cspm_gala or call (510) 869-6618 or (510) 869-8628.

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ALL NET PROCEEDS TO BENEFIT THE PODIATRIC MEDICINE SCHOLARSHIP FUND UNLESS OTHERWISE SPECIFIED. Tickets will not be mailed. Reservations will be held at the door. Tickets are tax deductible. Fair market value for each ticket is $110.

Fair market value of one table is $1,100.

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to preserve MICRA and maintain patient access to healthcare. Visit Californians Allied for Patient Protection (CAPP) - www.micra.org.

(Jodi Hicks, Legislative Counsel) DWC Ordered to End Collection of Lien Activation Fees A federal court has issued a preliminary injunction that prevents the California Department of Workers’ Compensation (DWC) from collecting activation fees on liens filed prior to January 1, 2013. The case, Angelotti Chiropractic, Inc., et al. v. Baker, et al., challenges the constitutionality of SB 863’s requirement that claimants holding legacy liens pay a $100 activation fee or lose the right to pursue payment on the claims.

The judge in this case ruled that the activation fees violate the Equal Protection Clause of the 14th Amendment of the United States Constitution. The fee for filing liens remains in effect. Only the lien activation fee (for claims filed prior to January 1, 2013) is affected by the ruling.

DWC began collecting lien activation fees last year as authorized

by SB 863, which made wide-ranging changes to California’s workers’ compensation system. Among them was an attempt to reduce the volume of liens by requiring payment of lien filing and activation fees to discourage the filing and pursuit of low-dollar-value liens by rendering them valueless. Under the law, holders of “legacy liens” those filed before the law took effect on Jan. 1, 2013 - are required to pay a $100 activation fee by Jan. 1, 2014 or have their liens dismissed.

The law also requires lien filing fees on liens filed on or after January 1, 2013. These filing fees are not impacted by the court’s ruling.

Effective immediately, lien claimants will not be required to pay the $100 activation fee in order to appear at a hearing or to file a Declaration of Readiness to Proceed.

For more information, see the DWC SB 863 pages http://www.dir.ca.gov/dwc/Liens/Liens_FAQs.htm (Source: CMA 11/26/2013) Medical Board Issues Alert On Fraudulent “Notice to Cease and Desist” Letter Regarding Daily Deal Sites It has come to the attention of the Medical Board of California (Medical Board) that a letter purported to have come from a Medical Board Investigator in the Discipline Coordination Unit has been received by a number of physicians throughout the State. This letter is entitled “Notice to Cease and Desist”, and warns physicians to immediately cease and desist from conducting any daily deal marketing arrangements with sites such as Groupon, Living Social, Amazon, etc.

This “cease and desist” letter (View Letter) was not generated by the Medical Board or any investigator employed by the Medical Board.

Disciplinary action will not be pursued against a physician’s license for failing to comply with these fraudulent cease and desist letters.

When the Medical Board receives any complaint regarding a physician, including the use of Groupon, Living Social, Amazon, or other marketing sites, the complaint is evaluated on a case-by-case basis to determine whether there is a violation of the law.

If you receive a cease and desist letter, and wish to verify its authenticity, please contact the Medical Board at 916-263-2528.

CPMA urges members to use extreme caution when using such sites. While each deal varies, typically the doctor agrees to give the coupon company a percentage of the revenue obtained from patients using the coupon (reports suggest as high as 50 percent) in return for the marketing company’s promotion of the practice through various types of coupons or “daily deals.”

Even if patients using such coupons are cash-paying and noninsured, the activity raises significant legal issues for providers.

Accordingly, doctors should act with extreme caution in this area, after obtaining the advice of an attorney experienced in health care fraud and abuse laws.

(Medical Board of California 11/13/2013) Feds to Crackdown on EHR Cut-and-Paste Function Federal officials say the cut-and-paste features common to electronic health records invite fraudulent use of duplicated clinical notes and that there is a need to clamp down on the emerging threat. That concern is enhanced by the fact that it’s too easy to turn off features of EHR systems that allow tracking of sloppy or fraudulent records.

In an audit report released on December 10, HHS agencies confirmed that they are developing comprehensive plans to deter fraud and abuse involving EHRs, including guidelines for cut-andpaste features. The issue arises at a time when critics say federally subsidized digital patient record systems are sometimes being used inappropriately by providers to drive up reimbursement.

Since 2011, hospitals, doctors’ offices and other providers have received federal subsidies totaling more than $17 billion to underwrite the high expense from ditching their familiar color-coded manila folder systems in favor of new computerized patient-record systems. Hospitals and doctors say EHRs allow them to better document the work they have always done, generating more accurate claims than before while meeting growing demands for efficiency.

But adoption of the new systems has coincided with a rapid rise in higher-cost Medicare claims. That has led to studies to see whether EHRs are enabling illegal upcoding. Officials at the Justice Department and HHS jointly published an open letter to healthcare providers in September 2012 warning that there are indications some companies were using the technology to game Medicare.

Critics say functions such as cut-and-paste make it too easy to bill for work that wasn’t actually performed, especially when the borrowed material comes from a different patient’s record.

A 2007 report (PDF) (http://www.rti.org/pubs/enhancing_data_ quality_in_ehrs.pdf ) from a government contractor, RTI International, recommended that users on the EHR systems should not be able to delete audit logs so that the information is always available for fraud detection.

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February27, 27,2014 2014 February February 27, 2014

AB 1868 1868 (Gomez) (Gomez) AB Medi-Cal Coverage Coverage of Medi-Cal of Podiatry Podiatry Services Services SUMMARY

THE BILL

AB 1868 will reinstate foot and ankle care by podiatrists in the Medi-Cal system.

AB 1868 would cover medical and surgical services provided by a doctor of podiatric medicine that, if provided by a physician, would be covered in the Medicaid system. Podiatrists have long been responsible for providing critical foot care services to complicated diabetic patients, infirm patients in skilled nursing and long term care facilities and scores of foot conditions causing pain and loss of productivity. Eliminating podiatric services from Medi-Cal has exacerbated an already acute access problem for the low income and disabled population. AB 1868 would reinstate podiatrists in Medi-Cal and provide better access to foot and ankle care for this vulnerable patient population.

BACKGROUND In 2009, “podiatry services� were eliminated in the state’s Medi-Cal program. This elimination removed Medicaid coverage by a type of provider (podiatrist), but not the services themselves. The same services provided by a physician or surgeon are covered in Medi-Cal, but podiatrists providing these same services are not covered.

THE PROBLEM Podiatrists perform physician services and have full medical staff admitting and surgical privileges in hospitals and surgery centers. Hospital podiatrists are now prohibited from providing on-call services to emergency patients in the Medi-Cal system, leading to a delay in cases of diabetic foot care or traumatic foot and ankle injuries. Eliminating coverage of services provided by podiatrists is a false savings, saving very little money in the short run, but resulting in much more expensive complications downstream. Essential foot and ankle services for Medicaid patients are now being provided at a costlier rate, often by emergency room providers, or care is being delayed as patients attempt to find a provider under the Medi-Cal system. Recent studies show access to podiatrists can prevent complications for patients and actually provide savings for delivery systems. Diabetic ulcerations are the primary factor leading to lower extremity amputations. According to a study conducted by Thomson Reuters Healthcare, among Medicare eligible patients, a savings of $4,271 per patient with diabetes can be realized over a three year period if there is at least one visit to a podiatrist in the year preceding ulceration. Each $1 invested in care by a podiatrist results in $9 to $13 of savings. Overall, patients with diabetes were less likely to experience a lower extremity amputation if a podiatrist was a member of the patient care team.

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FOR MORE INFORMATION Christina Romero Office of Assembly Member Jimmy Gomez christina.romero@asm.ca.gov (916) 319-2051 Jodi Hicks DiMare, Brown, Hicks & Kessler jhicks@lawpolicy.com (916) 662-1725

April 4 is National Walk to Work Day C P MA | C a l ifo r n i a P odi at r i c M e di c a l Asso c i atio n

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CMS Administrator Marilyn Tavenner and Jacob Reider, acting national coordinator of HHS’ health information technology office, said in responses to the OIG report that they are already developing a “comprehensive plan to detect and reduce fraud in EHRs,” as well as national policies on audit log functionality and copy-paste features.

A second report from the OIG on weaknesses in how CMS’ payment contractors monitor for fraud in electronic health records is slated to be published soon.

(Source: Modern Healthcare 12/10/2013) Noridian’s Endeavor Now Offers Remittance Advice The Noridian provider portal, known as Endeavor, was enhanced on November 15 and now offers the full remittance advice for checks that were issued in November and moving forward. This feature provides the same service that Palmetto GBA provided on its Online Provider Services portal. The Noridian feature supplements the existing Electronic Remittance Advice or the Standard Paper Remittance Advice primary method of receipt for providers. In order to obtain the PDF file, doctors must be a registered Endeavor user and have selected “Remittance Advice” access to the National Provider Identifier number.

Providers have two inquiry options available to them. They may request remittances issued within the last 30 days, or can request a remittance by date(s), check amount or check number. The Noridian system provides a list of up to 100 available remittance advices.

More details about the availability and limits for the remittance feature are available on the Noridian Jurisdiction E website.

(Source: Noridian Medicare 11/20/2013 ) New Workers’ Compensation RBRVS Physician Fee Schedule Effective January 1, 2014 As part of the reforms instituted by SB 863, the Division of Workers’ Compensation (DWC) will begin utilizing a new fee schedule based on the resource-based relative value scale (RBRVS) effective January 1, 2014.

The new RBRVS-based physician fee schedule will apply to services rendered on or after January 1, 2014, and will replace the current Official Medical Fee Schedule, which has not been updated to reflect new procedure codes and relative value units (RVU) since 1999. This newly adopted physician fee schedule will utilize current procedure codes and relative value units and will allow for annual updates to these values.

Under the new RBRVS Physician Fee Schedule regulations (located under Physician services http://www.dir.ca.gov/DWC/OMFS9904. htm#7 on DWC’s OMFS webpage), the calculations to determine maximum allowable amounts for each code will incorporate a number of factors, including the assigned RVU values for each code along with the yearly adjusted conversion factor determined by DWC. DWC has confirmed it will not be publishing a composite fee schedule for physicians to access.

(Source: CMAnet.org 12/11/2013)

Quarterly Results of Widespread Prepayment Review of Claims for Ankle-Foot/Knee-Ankle-Foot Orthosis (HCPCS L1970, L1960 and L4360) Current Review Results The Jurisdiction D, DME MAC, Medical Review Department is conducting a widespread complex review of HCPCS code(s) L1970, L1960 and L4360. The quarterly edit effectiveness results from June, 2013 through September, 2013 are as follows: The L1970 review involved 244 claims, of which 207 were denied.

Based on dollars, this resulted in an overall claim potential improper payment rate of 84%.

The L1960 review involved 278 claims, of which 237 were denied.

Based on dollars, this resulted in an overall claim potential improper payment rate of 88%.

The L4360 review involved 1,516 claims, of which 1,323 were denied. Based on dollars, this resulted in an overall claim potential improper payment rate of 87%.

Primary Documentation Errors that Resulted in Denial of Claims • Treating physician’s records didn’t provide detailed documentation to support medical necessity of a custom rather than a prefabricated orthosis.

For custom-fabricated orthoses, there must be detailed documentation in the treating physician’s records to support medical necessity of custom-fabricated rather than a prefabricated orthosis.

This information will be corroborated by the functional evaluation in the orthotist or prosthetist’s records. This information must be available upon request.

• Criteria 1-5 were not met.

AFO’s and KAFO’s that are custom-fabricated are covered for ambulatory beneficiaries when the basic coverage criteria and one of the following criteria are met: 1.The beneficiary could not be fit with a prefabricated AFO; or, 2.The condition necessitating the orthosis is expected to be permanent or of longstanding duration (more than 6 months); or, 3.There is a need to control the knee, ankle or foot in more than one plane; or, 4.The beneficiary has a documented neurological, circulatory, or orthopedic status that requires custom fabricating over a model to prevent tissue injury; or, 5.The beneficiary has a healing fracture which lacks anatomical integrity or anthropometric proportions.

If a custom-fabricated orthosis is provided but basic coverage criteria and the additional criteria 1-5 for a custom-fabricated orthosis are not met, the custom-fabricated orthosis will be denied as not reasonable and necessary.

• Basic coverage criteria were not met.

Ankle-foot orthoses (AFO) described by codes L1900, L1902-L1990, L2106-L2116, L4350, L4360, L4386 and L4631 are covered for ambulatory beneficiaries with weakness or deformity of the foot and See ON YOUR TOES on Page 40

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ankle, who require stabilization for medical reasons, and have the potential to benefit functionally.

• No detailed written order or dispensing order was provided.

All items billed to Medicare require a prescription. An order for each new or full replacement item billed must be signed and dated by the treating physician, kept on file by the supplier, and made available upon request. Equipment and supplies may be delivered upon receipt of a dispensing order except for those items that require a written order prior to delivery. A dispensing order may be verbal or written. The supplier must keep a record of the dispensing order on file. It must contain: • Description of the item • Beneficiary’s name • Prescribing Physician’s name • Date of the order and the start date, if the start date is different from the date of the order *Physician signature (if a written order) or supplier signature (if verbal order) For items that are provided based on a dispensing order, the supplier must obtain a detailed written order before submitting a claim. Detailed written order (DWO) is required before billing.

Someone other than the ordering physician may produce the DWO. However, the ordering physician must review the content and sign and date the document. It must contain:

• Beneficiary’s name • Physician’s name • Date of the order and start date, if start date different than date of order *Detailed description of the item(s) *Physician signature and signature date Going Forward Based on the high error rate, Noridian will continue with the Prepayment Widespread Review.

Education Resources It is important for suppliers to be familiar with the documentation requirements and utilization parameters as outlined in the AnkleFoot/Ankle-Knee-Foot Orthosis Local Coverage Determination (LCD) L142 and Policy Article A19800.

Suppliers can also review a specific policy Documentation Checklist for Ankle-Foot/Ankle-Knee-Foot Orthosis on the Noridian website Noridian provides educational offerings by scheduling supplier workshops, training opportunities, and presentations. Educational training and events are located at https://www.noridianmedicare. com/dme/train/.

Information about probe/error validation reviews may be found in CMS Publication 100-8, Program Integrity Manual (PIM), Chapter 3 located at http://www.cms.gov/manuals/downloads/pim83c03.pdf.

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February 2014 - DME Dear CPMA Members: I’m writing to update you on some new information regarding durable medical equipment (DME). We have been in discussion with Noridian representatives trying to address some of recent issues regarding DME denials. The denial rates for DME items including diabetic shoes, AFO’s and cam walkers are in the 80-90% range. Many of these denials were more a function of incomplete documentation and failure to submit proper paperwork rather than strict medical necessity. Enclosed you will find some information regarding proper documentation requirements that Noridian expects when reviewing your claims.

When asked for records please submit All the pertinent information. If it’s not submitted your record may be deemed incomplete. The physician must have a face-to-face examination with the beneficiary within six months prior to the date of the written order. There must be documentation that the patient was evaluated and/or treated for a condition that supports the need for the DME item(s) ordered.

AFOs & KAFOs used during ambulation AFO codes: L1900, L1902-L1990, L2106-L2116, L4350, L4360, L4386 and L4631 Covered if Beneficiary meets the following criteria: • Patient is ambulatory –One area of confusion had been that if the patient had to be nonweightbearing while using a cam walker, this was considered

by Noridian to be a non-ambulatory patient and hence the cam walker would not be a covered service. This has been discussed and clarified with Noridian. To address this bullet point, there must be a plan to move the patient to an ambulatory status once treatment is completed noted in the medical record.

• Beneficiary could not be fit with a pre-fab AFO (and why); or • Condition is expected to be permanent or last more than 6 months; or • Need to control the knee, ankle or foot in more than one plane; or • Beneficiary has a documented neurological, circulatory, or orthopedic status; or • Beneficiary has a healing fracture –There must be detailed documentation in the treating physician’s records to support the medical necessity of custom fabricated rather than a prefabricated orthosis.

L4396 This device (static or dynamic positioning ankle-foot orthosis) is covered if ALL criteria 1-4 is met , OR criterion 5 is met: 1) Plantar flexion contracture of ankle (Dx 718.47) with dorsiflexion on ROM testing of at least 10 degrees (i.e., nonfixed contracture); and 2) Reasonable expectation of ability to correct contracture; and 3) Contracture is interfering or expected to interfere significantly with beneficiaries functional abilities; and 4) Used as component of therapy program which includes the active stretching of involved muscles and/or tendons • NOTE: The pre-treatment passive range of motion that was measured with a goniometer and documentation of an appropriate stretching program carried out by professional staff, in a nursing facility or caregiver at home must exist in the medical documentation OR

• Requires stabilization for medical reasons

Modifiers:

• Beneficiaries who meet coverage for AFO must also require additional knee stability criterion L4360 • Certain products may have both covered and non-covered uses, as defined by the braces benefit category, and must be coded based on the beneficiary’s condition. For example, when used as a brace for the treatment of an orthopedic condition, walking boots (cam walkers) are coded L4360 and L4386. However, walking boots (cam walkers) must be coded A9283 when used solely for the prevention or treatment of a lower extremity ulcer or pressure reduction. Remember that cam walkers are not covered for the treatment of ulcers so A9283 is not a reimbursable item.

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Documentation for a custom device must include:

5) Beneficiary has plantar fasciitis (Dx 728.71)

KAFO codes: L2000-L2038, L2126-L2136 and L4370

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Custom Fabricated Devices:

• Has weakness or deformity of the foot and ankle • Has the potential to benefit functionally

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• LT – Left side • RT – Right side • KX – Coverage criteria met and supporting documentation is on file • GA – Coverage criteria not met and ABN obtained • GZ – Coverage criteria not met, valid ABN not obtained Claim Submission Reminders • When billing for L2999 (Unlisted code), must include this information on the narrative line of your claim: – Narrative description of item or manufacturer name and model name/number – Manufacturer’s Suggested Retail Price (MSRP) – For replacement components, HCPCS code or manufacturer name and model name/number of base orthosis See ON YOUR TOES on Page 43

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APRIL IS FOOT HEALTH AWARENESS MONTH

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The month-long observance serves as an opportunity to get the word out to the general public about the importance of good foot health and the important role podiatric physicians play in the health care delivery system and keeping Californian on their FEET – Healthy, Active and Productive!

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C P MA | C a l ifo r n i a P odi at r i c M e di c a l Asso c i atio n 12/13/2012 11:34:28 PM

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• All codes for orthoses or repairs of orthoses billed with same DOS must be submitted on same claim • Must include appropriate ICD-9 diagnosis code for:

Detailed written order (DWO) is required before billing and must contain: – Beneficiary’s name

– Static AFO (L4396, L4392)

– Physician’s name

• 718.47 Contracture of ankle and foot joint • 728.71 Plantar fascial fibromatosis

– Date of the order and start date, if start date different than date of order

– Walking boot (L4631)

– Detailed description of the item(s)

• 713.5 Arthropathy associated with neurological disorders

– Physician signature and signature date

The following is an example of an appropriate chart note Chief Complaint: Recast for boot Subjective: Patient presents to the office for casting for neurwalker or CROW boot. At the time, a custom ankle/foot orthosis device for unloading pressure and realigning the foot and ankle with biomechanical functional foot, ankle and leg pad was prescribed for the left foot and ankle sure to the amount of charcot foot and ankle deformity. The custom device was chosen versus prefabricated device due to the degree of deformity and the potential for ulceration and infection.

It is expected that the patient will require the use of the ankle/foot orthosis for an extended period of time. The custom ankle/foot orthosis is utilized in an attempt to alleviate the need for surgery.

Goals of therapy are: 1) Reduced ambulatory pain 2) Improve foot and ankle joint function 3) Limit further progression of the patient’s Charcot condition 4) Improve stability

NOTE: Prior to 2-5-14, Noridian was reviewing claims and was requiring that this written order be on a separate piece of paper and signed by the doctor. After discussions with Noridian, if you are both the prescribing doctor and the supplier, you do not need to have this form separate from your chart note; this information can be part of your charting for that date as long as all required elements, listed above, for the detailed written order exists in the chart note. When this occurs, this becomes both the dispensing order and the detailed written order.

A DISPENSING ORDER must contain: • Description of the item • Beneficiary’s name • Prescribing Physician’s name • Date of the order and the start date, if the start date is different from the date of the order • Physician signature (if a written order) or supplier signature (if verbal order) Proof of Delivery (POD)

5) Reduce pressures of the foot and ankle

• Supplier Standards

6) Decrease MTJ instability

• Signed POD required verifying beneficiary received DMEPOS item

7) Reduce potential ulceration and limb loss

• POD must be available upon request

Documentation: • Dispensing Order • Detailed Written Order • Beneficiary Authorization • Proof of Delivery • Medical Records • ABN when applicable Detailed Written Order and Dispensing Order: –All items billed to Medicare require a prescription. An order for each new or full replacement item billed must be signed and dated by the treating physician, kept on file by the supplier, and made available upon request. Equipment and supplies may be delivered upon receipt of a dispensing order except for those items that require a written order prior to delivery. A dispensing order may be verbal or written. The supplier must keep a record of the dispensing order on file.

– If not provided, claim denied, overpayment requested – If no documentation provided on consistent basis, may be referred to Office of Inspector General (OIG) • Maintain documentation for seven years Method 1- Direct Delivery • Delivery directly to a beneficiary by a supplier • The POD record must include: – Beneficiary’s name – Delivery address – Sufficiently detailed description to identify the item(s) being delivered (e.g., brand name, serial number, narrative description) – Quantity delivered – Date delivered – Beneficiary (or designee) signature and date of signature See ON YOUR TOES on Page 45

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• Date of service = Date of delivery Method 2 – Deliver/Shipping Service • Delivery to beneficiary via shipping service • The POD record must include: – Beneficiary’s name – Delivery address – Delivery service’s package ID number, supplier invoice number or alternative method that links the supplier’s delivery documents with the delivery service’s records

– If the physician’s name submitted on the claim does not match their name in PECOS • www.noridianmedicare.com/dme/news/pecos.html There are Local Coverage Determinations (LCD) LCDs for the following DME products that you may want to familiarize yourselves with: • Home Glucose Monitors • Hospital Beds • Manual Wheelchairs

– Detailed description identifying item(s) being delivered

• Osteogenesis Stimulators

– Quantity delivered

• Power Mobility Devices

– Date delivered

• Pressure Reducing Support Surfaces – Group 1

– Evidence of delivery

• Pressure Reducing Support Surfaces – Group 3

• Date of service = shipping date

• Seat Lift Mechanisms • Transcutaneous Electrical Nerve Stimulators (TENS)

PECOS Requirement

• Wheelchair options and Accessories

• Claims may be denied if: – The ordering/referring physician is NOT in PECOS and eligible to order and refer – The ordering/referring physician is not of the specialty to order/refer

• Wheelchair Seating https://www.noridianmedicare.com/provider/updates/docs/ F2F_Examination_Prescription_Requirements.pdf Tony Poggio, DPM

Corporate Member Profile Blaine Labs®

4 Benefits of Dispensing Simply put, Blaine Labs is about practice growth, so instead of talking about us, we wanted to use our profile space to show you these benefits of in-office dispensing: Increases Revenue

Increases In-Office Patient Visits

Dispensing treatments in office allows your practice to make money that would otherwise go to a pharmacy. By selling Blaine Labs treatments directly, you’re allowing every “script” you write to benefit not just your patient, but you as well.

Increases Patient Convenience

The more you can interact with patients and monitor their treatment, the more loyal your patients will be to your business.

With increased patient visits, issues can be caught early and dealt with before they have the chance to develop into more serious problems.

Between long lines, choices, and extra travel, pharmacies are an inconvenience to your patients. By dispensing, your patients can pick up their treatment on the spot, right at your front counter.

Call (800) 307-8818 to talk the additional benefits of dispensing – including joining our $10K Club and our 100% Money-Back Guarantee!

Increases Patient Compliancy Dispensing allows you to reduce patient error by ensuring your patient gets the necessary treatment, giving you greater control over compliancy. Furthermore, you can eliminate external factors from preventing complete treatment for your patients, leaving them more satisfied with their treatment experience.

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Trade Payroll and HR Pressures for Peace of Mind Most business owners dread one word on a regular basis – payroll. It’s a big burden with little reward, especially if you think you’re saving time and money doing it yourself. Paychex simplifies payroll processing. Submit your payroll online, call your dedicated Paychex payroll specialist, or fax it in . . . and you’re done! We also offer other services to help manage your employees and benefits administration.

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Call 800-729-2439 today (mention code 5830).

M CP A R

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www.blainelabs.com

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CO O

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E TE M

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www.picagroup.com

www.bakopathology.com

omieralabs.com www.wmt.com

www.nsightglobal.com www.dermpathdiagnostics.com

www.integralife.com www.formula3.com

www.merzusa.com

DermaTran

www.stryker.com

H E A LT H S O L U T I O N S

www.dermatran.com

www.spectranetics.com

www.henryschein.com

www.samuelmerritt.edu/ podiatric_medicine www.pedorthiclab.com

pacificadvisors.com/podiatry

www.newbalance/nbrx.com

www.televeresystems.com

Support the Companies Who Support You!

California Podiatric Medical Association 2430 K Street Sacramento, CA 95816

western foot and ankle conference june 19 – 22, 2014 disneyland hotel & convention center anaheim, california

register early to take advantage of the

early bird discount ends march 23rd

visit www.TheWestern.org

for more information

get more for your money: • Economically conscious registration rates • 25 CE contact hours • 10 radiology CE contact hours • Dynamic lecture tracks • Distinguished faculty • Innovative instructional courses

• Hands-on surgical workshops • Billing & Coding updates • PICA presentation • 3-day educational seminar for podiatric medical assistants including radiology credits • 3 days of exhibits

• Exceptional room rates at the Disneyland Hotel and Grand Californian Hotel & Spa • Significant savings on Disneyland & California Adventure Park Passes • Optimal location near shopping, dining, entertainment and more!

2430 k street • suite 200 • sacramento, ca 95816 • (800) 794-8988