Patient dissatisfaction is more than a customer service issue – it can escalate into complaints, regulatory scrutiny, and even malpractice claims. For podiatric medical physicians and surgeons, addressing concerns promptly and professionally is essential to protect both patient relationships and legal risk.

High-risk diabetic patients are those with a significantly increased likelihood of developing complications such as foot ulcers, infections, or amputations if not closely monitored and managed. These patients may present with:

• Neuropathy
• Peripheral artery disease
• Foot deformities
• History of ulcers or amputation
• Multiple co-morbidities that complicate podiatric treatment

Managing these patients is one of the most liability-sensitive areas of podiatry. It’s essential to provide comprehensive care to improve outcomes and reduce professional liability risk.

When it comes to today's healthcare environment, cyber security breaches are an ongoing concern for providers and their practices. From phishing emails to ransomware attacks, healthcare organizations are frequent targets due to the high value of patient data and the complexity of medical systems.

As more podiatric physicians incorporate Durable Medical Equipment (DME) into their practices – from custom orthotics to diabetic footwear – understanding the regulatory and credentialing landscape has become increasingly important. One key requirement that’s often overlooked until it delays or derails your DME program is proof of Comprehensive General Liability (CGL) insurance.

As a podiatric medical physician, you have medical malpractice insurance to help protect you from claims related to patient care. While this coverage is essential, there are additional risks to consider. Coverages like a business owner’s policy (BOP) and workers’ compensation insurance can help provide an added layer of protection for your practice.

Nearly everyone texts to communicate. It’s quick, easy, and convenient. However, texting with patients carries professional, legal, and ethical risks, including:

1. Privacy and HIPAA compliance. Standard texting is not secure. Messages can be intercepted, viewed on shared devices, or accidentally sent to the wrong number. Therefore, any patient’s personal health information sent via text risks a HIPAA violation and possible fines.

Professional boundaries are the ethical, legal, and relational limits that define the interactions between healthcare professionals and their patients. They protect the therapeutic relationship by ensuring that it remains focused on the patient’s health, safety, and well-being. Maintaining these boundaries is crucial for fostering trust, preserving professional integrity, and avoiding conflicts of interest.

Patients recording, either audio or video, their encounters with healthcare providers has become increasingly common. While healthcare providers may be alarmed when a patient asks to record their visit, it is not necessarily a bad thing. Recording patient encounters has both risks and benefits.

Workplace violence in healthcare settings is on the rise, putting providers at risk physically, emotionally, and legally. According to the Occupational Safety and Health Administration (OSHA), healthcare workers are five times more likely to experience workplace violence than workers in other industries. For podiatric medical physicians, this presents not only a safety concern, but a risk management priority. Implementing strong de-escalation techniques can protect staff, improve patient care, and reduce liability.

The Growing Threat of Workplace Violence in Healthcare
Healthcare environments are particularly vulnerable to aggression and violence. Contributing factors may include:

It is not uncommon for lawsuits to arise from wound care treatment. You can provide care to the best of your ability, and sometimes poor outcomes still happen. A poor outcome does not necessarily mean medical negligence; however, when a poor outcome happens, patients can perceive that the standard of care was not provided, become unhappy, and file a lawsuit. Common allegations include delay in diagnosis, failure to properly treat, failure to timely refer, and failure to obtain informed consent. Therefore, it is of utmost importance to take measures to protect yourself and your patients during the wound care process.

As a doctor, you use your knowledge, experience, and medical judgment to determine the best course of treatment for your patient. However, adult patients with decision-making capacity have the right to choose or refuse to follow your treatment plan.

Imagine this scenario. You perform surgery on a patient and the patient does not heal as expected or has a complication. You perform another surgery to correct the problem, but the patient eventually needs further corrective surgery. Your relationship with the patient has deteriorated, and the patient decides to seek treatment from another physician. In the meantime, the patient’s bills are piling up and the patient is having a tough time paying the bills. To make matters worse, the new physician criticizes your surgeries. The patient decides to sue you.

Unfortunately, a patient death can happen during the course of podiatric care and treatment. A patient may unexpectedly die from a DVT/PE following surgery. A patient you are treating for an infection may develop sepsis and die. A patient you are treating for a lesion may eventually be diagnosed with cancer and die. These scenarios are traumatic for the treating physician, as well as for the deceased patient’s family. Not all deaths can be prevented; however, there may be warning signs that a patient is at risk for this tragic outcome. Here are some warning signs you should never ignore.

Patient/Family History
Obtain and document a thorough patient and family history at the patient’s initial visit, then review the history for any risk factors that might be relevant when creating your treatment plan. Document any potential risk factors, any further investigation performed, and your rationale for your treatment decisions. 

Lack of Treatment Progress
If a patient is not progressing as expected, reevaluate your treatment plan. Consider possible reasons for the lack of progress. Is your diagnosis correct? Does the patient have unmanaged comorbidities? Does the patient have the ability and resources to comply with the current treatment plan? Does the patient fully understand the severity of their condition and the necessity of compliance with your treatment plan? Does the patient have the proper nutrition to promote healing? There can be many reasons a patient is not progressing with treatment, and promptly addressing these reasons can potentially prevent a poor patient outcome, including death.

Complications

Recognize and address any complications a patient may have in a timely manner. Failure to recognize and address a complication – such as infection or circulatory issues – as quickly as possible increases the risk the patient will have a bad outcome due to the complication. Document the complication, your conversations with the patient regarding the complication, your treatment plan to address the complication, any referrals for further evaluation, and the reason for the referral, follow-up evaluations, and the patient’s response to treatment. 

A Patient Tells You Something Isn't Right
Patients know their bodies and know when something is just not right. Listen to them. Document their concerns and your immediate steps to address their concerns. In some cases, a post-op patient calls their doctor stating they feel anxious or just do not feel right, the doctor chooses not to evaluate the patient, and the patient dies from a pulmonary embolus. The patient’s concerns may not be indicative of a problem, but it is much better to rule out a problem than find out later the patient suffered a bad outcome from an unrecognized problem.

The Patient Doesn't Return for Treatment
If you are treating a patient that needs follow-up and the patient does not return for treatment, the patient needs to be informed of the necessity for continued treatment and the risks of not seeking further treatment. This is especially important if you have diagnostic study findings that indicate a potentially life-threatening problem, such as a biopsy report stating the patient’s lesion is cancerous. These patients sometimes fall through the cracks leading to prolonged treatment, deformity, pain and suffering, and even death. If the patient does not respond to phone calls, it is advisable to send the patient a certified letter, return receipt requested, detailing the patient’s condition, recommended treatment, risks of not receiving treatment, and the need to seek care from a healthcare provider. Document all conversations with the patient and phone call attempts in the patient’s medical record. Copies of any written correspondence with the patient and return receipts, if applicable, should be kept in the patient's medical record.

By being cognizant of these warning signs, you could save a patient’s life - or in the unfortunate and tragic event of a patient’s death, you will reduce your risk of a lawsuit alleging your actions or inactions resulted in the patient’s death.

Introduction
November is Diabetes Awareness Month. Diabetes, particularly type 2 diabetes, comes accompanied by a host of comorbidities that directly impact the type and effectiveness of care required in treating the lower extremity, specifically the foot and ankle. Podiatrists are trained in the recognition of these comorbidities as well as their influence in outcomes of treatment. In this article, we will examine prevalent comorbidities and relate them to the anatomical considerations of foot and ankle pathology and where issues in successful treatment can possibly arise.

Diabetes is essentially a systemic abnormality of insulin regulation or the body’s ability to process sugar correctly. This irregularity leads to many other organ issues that can then manifest in the lower extremity. In effect, the lower extremity mirrors systemic disease. The patient complaints and condition that can appear in a podiatrist’s office can be related to conditions that affect their whole body. The most common comorbidities related to diabetes that intersect with podiatric medicine and patient care are obesity, heart disease, cerebrovascular disease, peripheral arterial disease, kidney disease, neuropathy, retinopathy, immune system compromise, and mental health issues.

How do each of these comorbidities affect foot and ankle pathology in a holistic sense?

Artificial intelligence (AI) is generally defined as computer systems that can perform complex tasks that previously only a human could do, such as reasoning, decision-making, or problem-solving. AI is rapidly being integrated into our world, including healthcare. Proponents of the use of AI in healthcare believe it has the potential to make healthcare more efficient, less expensive, more accessible, and safer for patients. 

AI Software for Medical Documentation
One of the more common uses of AI in physician offices is software for medical record documentation. This AI software is being marketed as a tool to make documentation more accurate and less burdensome. AI medical documentation tools work by using advanced algorithms and machine learning techniques to analyze and interpret large amounts of data related to healthcare, including patient records, lab results, and clinical notes. A key component of these tools is natural language processing (NLP), which allows the AI to understand and generate human-like language. 
AI automates documentation by creating notes in real-time by listening to physician-patient communication. AI can collect, sort, and assemble clinical information from previous notes, laboratory results, reports, and other contents of the medical record and provide real-time recommendations using dynamic clinical data mining. Additionally, AI can automate billing and coding based on risk-adjustment factors and can also draft level-of-service recommendations.

Potential Risks of Using AI Software at Your Practice
While the advancements in AI and the opportunities to streamline processes at a doctor’s office are exciting, the use of AI in healthcare is not without risk.

We know you’ve dealt with patients who have their own agenda, who do not follow instructions, who are apathetic with their care and treatment, or who are otherwise “difficult.” These patients can be a source of frustration for you and your office staff. They take up more of your time (and your staff’s time) and tend to have poor outcomes – and consequently, also tend to be dissatisfied with your care.

Peripheral neuropathy is a general term that refers to nerve diseases that impact the nerves outside your brain or spinal cord and cause numbness, weakness, or pain, usually in the hands and feet. These conditions can result from traumatic injuries, vascular and blood problems, autoimmune diseases, hormonal imbalances, kidney and liver disorders, nutritional or vitamin imbalances, alcoholism, exposure to toxins, certain cancers and tumors, chemotherapy, or infections. One of the most common causes of peripheral neuropathy is diabetes.

Complex regional pain syndrome (CRPS) is a diagnosis that is frequently involved in medical malpractice lawsuits against podiatrists. It is not uncommon to see plaintiff attorney ads targeting individuals who have been diagnosed with CRPS. Why? Because the plaintiff’s medical expenses and other damages such as pain and suffering, lost wages, family disruption, and loss of quality of life can be quite high. Therefore, settlements or jury verdicts in these claims can exceed a million dollars.

The most common precursors to CRPS are fractures, surgery, sprains/strains, burns, cuts, being in a cast, and nerve injury. CRPS can occur in anyone at any age, but it is more common in women and in middle-aged individuals.

A patient suffers cardiac arrest while waiting in the exam room. An elderly visitor falls in the waiting room, is complaining of leg pain and is unable to get up. A diabetic staff member passes out from hypoglycemia. These are just a few examples of unexpected medical emergencies that could happen in a medical office.

As a podiatrist, you have no doubt seen patients with wounds, masses, or lesions on their lower extremities. If these wounds, masses, or lesions are later found to be skin cancer, the treating podiatrist is at risk of a lawsuit. A common allegation in these cases is a delay in diagnoses and treatment of cancer resulting in harm to the patient. Skin cancer developing on the lower extremities is not uncommon and podiatric medical physicians are in a unique position to detect these types of cancers on their patients.

If you prescribe opioids in your practice, it is important to be familiar with current clinical practice guidelines for prescribing opioids, DEA requirements, and federal and state laws and regulations to reduce your professional and administrative liability risk. In this article we will discuss some of the guidelines, requirements, and regulations relating to prescribing opioids.

Over the years, there have been many lawsuits filed against physicians because the patient was not satisfied with a surgical outcome. It could have been a post-operative complication, delayed healing, prolonged pain, cosmetically undesirable result, or a host of other reasons. In the majority of these cases, the physician was found to have acted within the standard of care and the case was eventually dropped or in the event the case went to trial, the jury found in favor of the physician. In the meantime, a lot of time, effort, money, frustration, and stress was spent on claims in which the medicine was good.

So, Why Do These Patients Sue?
This quote by S. Jay Jayasankar, MD is insightful, “The patient’s expectation, not ours, is the yardstick by which our patients measure the course of recovery, occurrence of complications, and the outcome.” If the patient’s expectations are not met, the patient is more apt to sue, regardless of whether malpractice occurred.

Regardless of how long you've been practicing, you have undoubtedly come across a patient that has unrealistic expectations for surgery. This typically manifests in an unhappy post-operative patient. The patient may complain that their scar is too big, their recovery is taking too long, they are not able to return to work when they want, they cannot return to sports activities as quickly as they would like, they can’t wear stilettos, and the list goes on. And as we all know, an unhappy patient is more likely to file a lawsuit than a happy patient.

As you could probably surmise, amputations are a leading factor in malpractice suits against podiatrists. So, how do you reduce the risk that a complication will result in amputation? And if amputation is necessary, how can you reduce the risk of a lawsuit being filed?

As a practitioner, you have most likely experienced an unexpected outcome in your care and treatment of a patient. It does not mean you are a bad physician. It happens even with the most experienced physician, but it can be very distressing for you and your patient. How can you protect yourself from risk and maintain a healthy physician-patient relationship in the event of an unexpected outcome?

Start at the Beginning
First, prepare your patients for the possibility of an unexpected outcome. At the beginning when you’re developing a treatment or surgical plan with your patient, discuss the risks and benefits of your plan, including the most likely complications or side effects. Include a discussion of any risk factors that the patient may have that might affect the success of your plan. For example, a patient would be more likely to experience post-operative complications if they are a smoker. With medically complex patients, discuss the treatment challenges and the fact that they may require treatment from a team of specialists/healthcare professionals.

We continue to receive questions from podiatry practices regarding the use of and billing for amniotic fluid injections for musculoskeletal purposes. We recently published an article, “Caveat Emptor Vendor: Skin Substitutes & Injectable Amniotic Fluid” that details some real-life examples of the risk providers incur if they fail to do proper due diligence in these situations. In the article below, we continue the conversation around amniotic fluid injections by answering three of the most asked questions so you can make informed decisions at your practice.

In the past year, we have seen a dramatic uptick in audits and overpayment claw backs involving two high-dollar products: skin substitutes for wound care and injectable amniotic fluid used for musculoskeletal conditions. While there is no question that these products work, practitioners are often guilty of listening uncritically to sales pitches by vendors who promise high reimbursement and certain payer coverage. Failure to conduct due diligence on these products puts providers at high financial risk because of the substantial cash outlay required to purchase the products, typically upfront.

It is not uncommon for a podiatric physician to be named in a lawsuit when a patient suffers a DVT/PE following podiatric surgery or treatment requiring immobilization. Allegations against the physician commonly include:

All physicians know a medical record must be maintained on each patient. Why? Medical record documentation is required by state and federal laws. Proper documentation is important for continuity of patient care and necessary to receive reimbursement for services rendered. The patient’s medical record is a legal record of the care you provide to the patient and is a valuable tool in your defense should a medical malpractice lawsuit be brought against you.

If you’re thinking about retirement, it’s prudent to start planning well in advance. If you are a solo practitioner, will you sell or wind down your practice? If you are in a group practice or employed, what are your obligations regarding providing notice of retirement? What are your state licensing board’s requirements regarding retirement? How will you retain your medical and business records? How will you notify your staff and patients of your plan to retire? What do your contracts with health insurers require when you retire from practice? Do you need to purchase professional liability insurance “tail coverage”? 

Introduction to Integrative Medicine
Integrative medicine is an approach to wellness that is growing in popularity in the United States. It is patient-centered and combines conventional medicine and complementary medicine to treat the person as a whole. It addresses many factors, including the physical, emotional, social, spiritual, and environmental influences on a person’s health status. Integrative medicine focuses on the broader concepts of health that promote a person’s overall health and future well-being. Reviews and clinical studies have shown positive outcomes for patients and providers who participate in integrative medicine programs.

Background: Big Changes from 2021
The Evaluation and Management (E/M) codes have been based on the 1995 and 1997 E/M Guidelines for what seemed like forever. The E/M codes were based upon three key components: 1) the history, 2) the examination, and 3) medical decision making all performed at the proper levels. On January 1, 2021, everything changed. The changes were specific to Evaluation and Management services that were performed in the office or other outpatient places of service only. Clinicians are now able to use either time or medical decision making to select an E/M code. There is no required level of history or examination for the E/M codes.

Now: Highlights for 2023
On January 1, 2023, the changes that were made to E/M services that were performed in the office or other outpatient places of service were expanded to the other places of service. The E/M codes include a medically appropriate history and/or examination, when performed. The nature and extent of the history and/or physical examination are determined by the treating physician or other qualified health care professional reporting the service. The care team may collect information, and the patient or the patient caregiver may supply information directly (e.g., by electronic health record HERR) portal or questionnaire that is reviewed by the reporting physician or other qualified health care professional. The extent of history and physical examination is not an element in the selection of the level of these E/M codes.

Time is defined as total time spent, including non-face-to-face work done on that day and no longer requires time to be dominated by counseling. It includes time regardless of the location of the physician or other qualified health care professional (e.g., whether on or off the inpatient unit or in or out of the outpatient office). It does not include time spent in the performance of other separately reported service(s).

The definitions of medical decision making (MDM) are the same as the definitions of medical decision making that went into effect for office and other outpatient places of service on January 1, 2021.

While most healthcare providers are compassionate and want to provide optimal care to their patients, everyone has biases and knowledge gaps that may hinder the provision of quality healthcare. These biases and knowledge gaps can lead to:

• Barriers to care
• Miscommunications
• Misdiagnosis
• Lack of trust

As the United States continues to become more diverse, cultural awareness and competence are key for healthcare providers.

Finding yourself in a situation where a patient is unhappy with their treatment and asking for a refund, what should be your response? For example, you may feel that your work is satisfactory, and you are unwilling to provide a refund to the patient considering all the time you spent on their care. Or you may be seeking a quick resolution to the situation. In this article, we’ll take a closer look at how to handle patient refunds.

Written by: J. Kevin West & Jamie L. Riley

PICA has become aware of situations in which vendors of skin substitute products offer rebates to doctors who purchase those products. Questions have arisen regarding what legal requirements, if any, are doctors required to comply with to ensure that any rebate payments received do not subject a doctor to the criminal or civil penalties in the Anti-Kickback Statute (AKS).

The AKS imposes criminal and civil penalties if a doctor knowingly receives any remuneration in return for purchasing or ordering any item for which payment may be made by a federal healthcare program, such as Medicare. In short, the AKS prohibits kickbacks between doctors and vendors. “Remuneration” under the AKS specifically includes rebates. However, the AKS contains an exception for certain “discounts” if the discount is properly disclosed and appropriately reflected in the costs claimed or charges made by the doctor to Medicare. This exception is commonly referred to as a “safe harbor” provision.

In a word, yes. Many podiatrists significantly underestimate how much a breach will cost, and think they can self-insure it. Outlining what will happen in the event of a breach is very useful when understanding the value of cyber liability coverage. Below are a variety of claims scenarios that help illustrate the severity of cyber claims, and how widespread cyber breach activities are throughout the healthcare industry.