News From ACFAS

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Don't forget, if you attended the Annual Scientific Conference in San Antonio, then you're eligible to download the session handouts.

All handouts are now available for download at acfas.org/sanantonio ACFAS launched this new, unique, members-only benefit at the Annual Scientific Conference—the Credentialing and Privileging Advisory Team (CPAT). Ten specially-trained experts who are experienced in the ins and outs of getting and staying on staff at healthcare institutions are ready to help you with challenges and questions related to privileging and credentialing issues facing today’s foot and ankle surgeons.

To access this unique member benefit, please e-mail Credentialing@acfas.org Top reasons not to miss this educational offering…

1. Gone are the Superbills: Start now to prepare for the ICD-10. While delayed for Medicare, private payers are moving forward with this historic change for medical billings and collections.
2. CMS’ Meaningful Use EHR Incentive Programs: Learn the latest about requirements and attestation. Foot and ankle surgeons can earn up to $44,000 under Medicare over 5 years.
3. Claims Rejections Due to HIPAA 5010? CMS acknowledges issues, and your Medicare Administrative Contractor (MAC) can’t solve them all. Do you have difficulties with practice management system software, clearinghouses and commercial payers?
4. Confused with the new Independent Payment Advisory Board (IPAB)? What does this really mean for foot and ankle practices?

ACFAS’ Perfecting Your Practice workshop uniquely provides expert legal tools and practice contract solutions presented by an attorney specializing in Health Law. ACFAS proprietary resources related to buying, selling or moving your practice to a hospital has all the resources foot and ankle surgeons need to navigate this complicated, legal world.

Join us in Portland, OR on June 1-2, or in Arlington, VA on October 12-13, for a two-day workshop; or attend one of two roundtable events: Contract Consternation or Coding and Practice Professionals Interactive Session.

To register, visit the web link below. For additional questions, email jane.battison@acfas.org or call (800) 421-2237.

Legal Briefs

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The U.S. District Court for the District of Kansas recently determined that a practice group did not violate a doctor's employment contract by terminating his services after finding out that he had engaged in extracurricular work without his supervisors' awareness or permission. In passing a summary judgment for the employer, Galichia Medical Group, the court ruled that Philip Totonelly breached his employment contract by moonlighting and by not accounting to Galichia for the payment he received from his extra work. The court said the employment agreement explicitly prohibited moonlighting, and dictated that any fees obtained for such services would belong to the practice group. The court also found that Totonelly violated the contract by failing to complete patient medical records following his initial notice of termination.


A Nevada state statute dictates that a doctor alleging that a public hospital violated his constitutional rights by suspending his staff privileges without giving him prior notice or a chance to be heard can recover only limited damages on a second claim that the hospital breached the implied agreement of good faith and fair dealing associated with the suspension. The court rejected the plaintiff's assertion that the cause of action was based in contract, rather than tort; in Nevada, damages available against public entities in contract actions are unlimited. The court emphasized that the plaintiff sought damages that are not available in contract, such as punitive and emotional damages; the state precludes punitive damages awards in contract actions, nor is remuneration for emotional suffering caused by a breach of contract available in Nevada.


In the case of Broad Street Surgical Center v. UnitedHealth Group, there are charges of negligent misrepresentation brought by the surgery center against health insurers that are not preempted by the Employee Retirement Income Security Act (ERISA), and providers that receive guarantees that their patients are covered by health insurance may have remedies under state law. The U.S. District Court for the District of New Jersey determined that Broad Street Surgical Center could seek to recover on the state law theory against UnitedHealth Group and United Healthcare Services because the claims brought based on that theory were sufficiently separate of the underlying, ERISA-governed health plans.

The court additionally ruled that most of the state-law claims brought by Broad Street as an assignee of the rights of the ERISA plan enrollees were preempted and had to be filed as ERISA claims under Section 502(a) of the act. However, Broad Street could not pursue the remaining state-law claims brought on its own behalf since those claims were expressly preempted for "relating to" an ERISA plan. Contract and other claims involving one plan not governed by ERISA also could move forward, although the court rejected unjust enrichment, implied contract, and tortious interference claims expressed with respect to that plan without giving Broad Street a chance to revise.

The court pointed out that, in accordance with the complaint, the outpatient service provider and the United Health entities had, at least at first, a cooperative relationship, with the out-of-network surgery center being paid as either a service provider or as an assignee of its patients. Following September 2009, UnitedHealth ceased paying based on its asserted claim that Broad Street was not licensed as an ambulatory care facility by the New Jersey Department of Health. The claims expressed in the complaint were founded on allegations that Broad Street acquired the consent of UnitedHealth representatives before treating each of the plan enrollees. The court said it could be anticipated that incorrect information on whether the services were covered would cause Broad Street and its patients economic damage because the health plans would not cover the cost of the medical care.

Foot and Ankle Surgery

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A study was performed to gain insight on risk factors for lower extremity amputation (LEA) in patients of diabetic foot disease with different Wagner categorizations. Demographic traits, laboratory data, disease history, ankle brachial pressure index (ABI), and Wagner classification were considered as independent factors to forecast the therapeutic outcome, and risk factors for LEA in different Wagner grades were subjected to further analysis. Multivariate stepwise ordinal logistic regression was carried out. Nearly 20 percent of 789 study subjects received major LEA and 22.9 percent received minor LEA. A significant correlation between higher Wagner grade, lower ABI, serum albumin and hemoglobin, and elevated white blood cell (WBC) count and a greater risk of LEA was determined. Stratification by Wagner classification demonstrated that most of the above predictors and estimated glomerular filtration were identified only in grade 3. While in grades 2 and 4, WBC count was detected as primary predictor positively associated with a higher risk of LEA.


Research was performed to assess calf muscle stretching's impact on ankle joint dorsiflexion and subsequent changes within dynamic forefoot peak plantar pressures (PPP), force, and temporal parameters. The study involved 13 runners with ankle joint equinus who performed calf muscle stretching twice daily on an inclined ramp. Measurements were collected on the first day, the fourth week, and the eighth week. Differences across the three data collection sessions were evaluated via repeated measures ANOVA with Bonferroni-adjusted post hoc comparisons. The calf stretching regime boosted ankle joint dorsiflexion from 5 degrees to 16 degrees. The adaptive kinetics induced by the increased ankle joint range of motion included significantly greater forefoot PPP and maximum force during stance phase but shortened time between heel contact and heel lift and total stance phase time.


A systematic review of the literature concerning the effectiveness and safety of bisphosphonates in acute Charcot neuropathic osteoarthropathy was performed, and 10 studies on this procedure were identified and included in the analysis. Four clinical trials were published, and three of those trials were randomized. Bisphosphonates seemed to trigger significant reductions in skin temperature and bone turnover markers in comparison with placebo, without serious negative events. Still, the immobilization time was not reduced by bisphosphonates, and no data regarding their long-term effects was available.

Practice Management

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Physicians and healthcare organizations can use social media such as Facebook, Twitter, and YouTube to build relationships with patients and members of the community. However, engagement in social media must involve more than posting basic healthcare information. St. Peter's Hospital in Helena, Mont., launched a Facebook page in April 2011, gaining more than 1,000 followers after the launch of a "cute baby contest" online and media coverage of the first baby of the new year. Sherman Health, a hospital in Elgin, Ill., has gradually come to use social media with a goal to start discussions with the community. Despite the serious nature of healthcare, organizations should include some humor in their social media, or else a site may lose readers and followers. When using social media for a contest or marketing campaign, organizations should incorporate as many sites and channels as possible. For example, Sherman Health uses Facebook applications to run contests, but connects all of the social media channels through its blog. Organizations should also keep their social-media budget low, including contest prizes. Social media must still be connected to a business purpose, which promotes the organization and helps executives understand that it does have a goal.


If the flow of patients moving from the reception area to the examination rooms is erratic, it may signal the need for the practice to assess its communications system, patient processing systems, and space. The first step should be evaluation of the practice's information flow, and the impact of electronic health record systems, electronic testing equipment, light signaling systems, etc., should be considered. Eliminating patient flow bottlenecks require bringing the appointment template and staffing numbers in sync with each doctor's ability to see patients and the number of staff allocated to handle that volume of patients, and crucial to this synchronization is a time study concentrating on physician time and not on patients, charts, or other practice aspects. Office protocols constitute the next component in streamlining patient flows.

Based on what a patient presents with, the practice should have protocols established so that staff knows what the doctor requires before he sees the patient, and these protocols must be kept constant. In group practices where clinical staff members vary from session to session, each doctor should have a team leader tasked with coordinating that session's team members so there is day-to-day continuity. Changes to space, such as the volume of space, the space's layout, or both, must be achieved while the practice is in operation, and a number of questions should be answered prior to space assessment. Those issues include the number of doctors and midlevel providers in the practice, those clinicians' subspecialty interests, the services provided by the practice, and whether the practice intends to open satellite offices. When making space evaluations, the number and types of rooms needed must be considered in addition to total square footage.


Physicians and hospitals looking to launch or remodel a website should not look to other medical sites for ideas, according to a study in the January/February issue of the Journal of Healthcare Management. Researchers looked at the elements of an effective website and measured the performance of some of the nation's hospitals and health systems' sites. This included 636 websites listed in the American Hospital Association's directory, which the researchers analyzed for ease of use (accessibility), overall content quality, how readily information is found via search engines, and site design. Many websites were lacking in accessibility, a problem that must be fixed if an organization wants to reach as many people as possible. Content should be accessible to those with low computer literacy levels, consumers with physical disabilities, or people who use nonstandard browsers. While the general rule for websites is to write at an 11th-grade reading level, the analysis found that many hospital sites write to a graduate degree level, with jargon-heavy language or using only the acronym of a term. The report also noted that the growing importance of social media and quality reporting on the websites will present challenges in the future.

Health Policy and Reimbursement

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A rule proposed by the Centers for Medicare and Medicaid Services (CMS) that would extend responsibility for Medicare overpayments through a 10-year "lookback period" is generating concern from healthcare providers. The lookback period now is generally about four years, and CMS estimates that extending the review by another six years would cost as much as $58 million in reporting-related expenses each year for about 125,000 providers and suppliers. Those opposed to the propose rule said CMS is a little too zealous and that a 10-year lookback would create an undue burden for most healthcare providers. Still, some said the proposal did not come as a big surprise, particularly in light of the current political climate. The American Hospital Association and the American Medical Association are drafting letters to CMS, detailing their opposition to the proposed rule. Meanwhile, CMS said in the proposed rule that a 10-year lookback period would make it consistent with the False Claims Act statute of limitations and that the proposal is "appropriate for several reasons."


House Republican aides say language to repeal the health reform law's Independent Payment Advisory Board (IPAB) has been bundled into a medical liability reform bill that House members are expected to vote on next week. Included in the bill is the Medicare Decisions Accountability Act of 2012, which would repeal the Patient Protection and Affordable Care Act provision calling for a 15-member committee tasked with limiting Medicare cost growth. Two House committees—Energy and Commerce and Ways and Means—have approved the IPAB repeal measure. Last week the Congressional Budget Office (CBO) reported that repealing IPAB would add some $3.1 billion to the federal deficit, while a CBO estimate indicated that the tort-reform legislation could cut the deficit by $57 billion over a decade.


The Society of General Internal Medicine plans to launch an independent commission to assess how physicians are paid and how pay incentives are linked to patient care. Additionally, the National Commission on Physician Payment Reform will issue recommendations on how to reform the physician payment system in an effort to restrain healthcare costs while at the same time optimizing outcomes for patients. The Commission will assess how physicians are paid, as well as potential impacts of proposed healthcare payment models. The Commission also will examine efforts to incorporate quality into the current pay system and assess the opportunities and risks of the healthcare payment configurations being implemented as part of the Affordable Care Act. It is expected to consider incentives and safeguards surrounding physician payment, as well as assess forms of physician payment that maximize good clinical outcomes.

Medicine, Drugs and Devices

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A University of Chicago study published in the Archives of Internal Medicine found that resident doctors were able to order tests and procedures for patients with greater efficiency through the use of iPads on their rounds. Most residents who used iPads to access patient records and coordinate their care said they shaved about 60 minutes off their workload per day, while researchers also discovered that internal medicine trainees tended to put in orders for patient procedures earlier than before they obtained an iPad. The devices let residents view patients' electronic health records, contact the hospital lab or other departments if they needed tests performed, show patients their own x-rays and other test results, and access medical journals. "Clearly this is demonstrating a new trend in integration of personal computing devices with the electronic health record," says Yan Xiao with the Baylor Health Care System in Dallas.


Pfizer, Johnson & Johnson, and Regeneron Pharmaceuticals won the backing of a U.S. advisory panel to continue development of a class of experimental painkillers that have been linked to joint failure. The Food and Drug Administration advisers voted unanimously that the benefits of enhanced pain relief outweigh the risks of the so-called anti-nerve growth factor drugs. Studies on the class of drugs were halted in 2010 after the joint issues were reported. Trials for osteoarthritis and back pain, among other chronic conditions, are on hold while a study in cancer pain is ongoing.