Practice Management: Pre-Signed Forms, a Second Pair, and a Disclosed Interest
A local podiatry practice refers a steady stream of patients to your facility. Their office manager asks you to do three things: (a) pre-sign a stack of "certification of need" forms so their front desk can attach one to any diabetic shoe order; (b) bill a patient's second pair of depth-inlay shoes in November as a "replacement due to wear," although the first pair was dispensed in February; and (c) describe an $85 prefabricated gel insert as "custom molded" so the patient's secondary insurer will cover it. The referring podiatrist is a 12% owner of your facility, which patients are not told. You have a signed prescription for the first pair on file.
1. Evaluate (a), (b), and (c) and state what you would do about each.
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All three are misrepresentations, and two are potential false claims. The answer to all three is no.
(a) Pre-signed certifications: refuse. A certification of need is an attestation that the physician examined the patient and that the patient meets the criteria; it must be signed and dated after that encounter. A form signed in advance and attached to an order for a patient not yet seen is a false attestation, and it destroys the evidentiary value of every other form from that office. Offer a compliant workflow: send the order and the form together and ask the office to sign after the visit, with a turnaround you can live with.
(b) February pair billed as a November "replacement due to wear": refuse. The reason for replacement is a factual statement, and your own delivery records contradict it. If the patient needs a second pair, offer it as self-pay, or document the actual clinical justification if one genuinely exists and let the payer decide. Do not manufacture a reason.
(c) "Custom molded" for a prefab gel insert: refuse. Describe and bill what was actually delivered. Mislabeling a prefabricated item as custom to obtain coverage is a false claim, and it also misleads the patient about what she is receiving. Explain the accurate description and the actual cost, and let her decide.
Handle it once, in writing: state the policy to the office manager, in writing, and copy your own records. Repeat requests are a business-relationship problem, not a one-off.
2. What are your obligations regarding the podiatrist's 12% ownership interest?
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Disclose it, in writing, at the time of the referral. When a referring physician has an ownership interest in the supplier, the patient is entitled to know before deciding where to obtain the item, and is entitled to know they may obtain it elsewhere. An undisclosed financial interest in a referral stream is the core of the anti-kickback and self-referral concerns, and it also undermines the patient's consent to the arrangement.
Practical steps:
- A written disclosure form, given to the patient at the time of the referral or at intake, signed and dated, and kept in the chart.
- An explicit statement that the patient may obtain the footwear or insert from any supplier.
- Staff scripted so the disclosure is routine, not an awkward afterthought.
- Check the payer's rules and your state law as well - some require the disclosure to appear on or accompany the claim, and the specifics vary. Confirm the current requirement rather than relying on memory.
Do not assume that because the referral is clinically appropriate, the relationship needs no disclosure. The disclosure obligation is independent of whether the referral was justified.
Also consider: if the arrangement is structured in a way that compensates the practice per referral rather than reflecting fair market value, that is a separate problem that needs legal review - raise it rather than working around it.
3. What belongs in the chart for the first pair that was dispensed in February?
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A defensible record for therapeutic footwear should let a reviewer reconstruct the clinical need, the order, the device, and the delivery without talking to you:
Order and encounter
- The signed and dated prescription/order from the certifying physician, naming the items.
- Documentation of the required face-to-face encounter within the applicable window before the order, and that the physician is managing the condition.
Clinical findings supporting need
- Monofilament or other sensation testing with the sites recorded.
- Deformity findings, prior ulceration or amputation history, and current lesions or calluses.
- Vascular status, including ABI where available.
- Footwear history and the reason the current shoes are inadequate.
Device
- Make and model, depth, inlay type, materials, and every modification, described concretely rather than as "custom."
Fitting and delivery
- Fitting notes, the date dispensed, who received it, and the patient's or caregiver's signature.
- Any advance beneficiary notice or financial disclosure signed.
- The follow-up plan and interval.
Why: if a claim is reviewed, the record is the claim. A chart that says only "diabetic shoes dispensed" cannot support the same billing as a chart that documents insensate sites, a prior ulcer, and a specific accommodative design.