Does Medicare Really Care?
"Routine" Toenail Care: When is it "covered?"
Medicare doesn't care !
Simply put, Medicare does not want to pay for ANY toenail care that is not (what IT determines to be) a medical necessity and, even then, not in all circumstances. They don't care if you can't reach your toes easily or at all (for any reason). They don't care that you cannot see well enough (or at all!) to tend to your own toenails or feet. They don't care if you have a "hard time" cutting your nails if they are too thick or hard. They don't care if your toenails become thick or sore a couple months after your last podiatric professional care. They don't care if you are 65, 75, 85 or 95. Medicare was created by your politicians and is administered by their bureaucrats.
Misinformation abounds !
Furthermore, the people who staff the Medicare phones in Wallingford are notorious in giving incomplete or less than accurate information to Medicare subscribers who call for more information about foot care inclusions and exclusions. This is not surprising; it is all rather convoluted. They will tend to tell people what sounds reasonable and compassionate (when, in fact, the rules are not reasonable and not compassionate) either out of ignorance or a misguided effort to "please the public". Simply put, the advice these Medicare staffers give just cannot be relied on. Many times, they complicate the doctor-patient relationship with their inaccurate information.
Participating Podiatric Physicians (foot doctors), and especially those who belong to the Connecticut Podiatric Medical Association, such as I, have received detailed, changing and sometimes conflicting information from Medicare about what they feel is included and excluded forms of care. Unfortunately, this information from Medicare has changed over the years, in its scope, its particulars and its application. Even your medical doctor (MD) does not usually have the experience to accurately tell you when your foot care (by MD or DPM) is to be covered or not. Thus, I submit that only CPMA participating podiatric physicians (foot doctors) should be relied upon to give you honest and accurate information here: WE do care.
IRS, FBI or Medicare !
Medicare is classical BIG government created by our elected politicians. You must understand that there are very real and serious legal consequences and penalties if these Medicare rules are knowingly bent or broken. If YOU entreat or urge your foot doctor to "bend the rules" so that your care is covered (when and if it should not be), it is HIS or HER neck, not yours, which will take the axe, if he or she acquiesces. Medicare will always go after the provider for any abusive or fraudulent claims, not you the patient, even if YOU feel you should have been covered when you urged his complicity. They will telephone you and interrogate you in such a manner as to make a case against a provider they are investigating; they will even come to your house and ask to examine your feet if they are trying to "build" a case against a "suspected", abusive biller. They can literally storm a provider's office to gather purported incriminating `evidence' against him/her.
Would YOU personally be willing to pay tens or hundreds of thousands of dollars in fines or spend months in prison for your foot doctor just to have your nail care covered when it should not have been?
When is "Routine" not routine?
Only in the most narrow circumstances will Medicare cover "routine" trimming of toenails: A medical necessity, which THEY define, must be present and documented. Medicare does NOT care if you have an implanted heart valve, or an artificial hip or knee joint, or have an immunological deficiency (either from infection or from medical treatments) which puts you at risk of infections arising from normal podiatric care. Medicare does NOT care if you have diabetes mellitus (whether "controlled" by insulin, pills, or diet) if there are NOT additional, complicating factors which would put your feet at risk.
Most commonly, "coverage" is usually extended to people with significant peripheral vascular disorders (blood circulation problems and diseases in the feet), or, significant peripheral neurologic disorders (nerve problems and diseases effecting the feet), or a significant risk of excess bleeding because of the use of anticoagulants (blood thinners, such as Coumadin, at least in Connecticut, but not some other states!). Your foot doctor has all the details: WE do care!
Cross the "t" and dot the "i" !
Medicare requires that very specific findings and conditions which THEY list be documented in your foot doctor's records before they will agree that your "routine foot care" (including nail trimming) was a covered service. Medicare requires that this information be documented by a Medical Doctor physician, in writing. In some, specific instances, this documentation must be obtained EVERY six months. Additionally, Medicare expects YOU to be able to tell your foot care provider, on the day you go for "routine" foot care, the exact DATE (month, DAY, and year) when you were LAST seen by your physician (or appropriately tested) for certain medical conditions. When you WILL be seeing your physician does NOT matter. These are Medicare's rules, not those of your podiatrist! You signed the contract, so, they are dealing and you have to play their game.
Thick toenails: Routine ?
Let's say that you have some really thick toenails. You cannot easily manage them with everyday nail scissors or clippers, even if you could see, reach or feel them. And, let's also say that you DON'T have any of the above, special, documented,"qualifying" conditions for nail trimming or thinning (debridement). Medicare doesn't care if they have arisen from, say, psoriasis, fungus, injury or happenstance. It's just NON-covered routine care to them.
But, Medicare says, if the your nails are SO thick that the nails are PAINFUL AND significantly interfere with your ability to walk in shoes in comfort), then Medicare says that care for such nails MAY be covered. How thick is thick; they are vague. How painful is painful; they can't say. How much must your walking be impaired, they don't explain. Furthermore, Medicare may additionally ask the podiatrist take a picture of your nails to help substantiate at least their thickness. They don't believe what the doctor says, only what is reported in the chart. If the doctor's chart is not to their liking, his or her ability to practice is then on the line.
What if the you cannot walk well anyway and perhaps have to use a wheelchair or other walking aid? Medicare says that, then, your thick toenails must be thick, and painful and put you at imminent RISK of bigger problems, such as infections or inflammations around the nails. How much risk is a big enough risk? Do you get the feeling that they really don't want us to take care of you? We get that feeling too. We, however, do care!
So, where does that leave you and your podiatrist? If your nails are not thick "enough", your care is routine and NOT covered. If you do not report that your nails hurt you or are painful, then your care is routine and NOT covered. If you do not complain that you having trouble walking because of your thick and painful toenails, your care is routine and NOT covered. If your toes are not inflamed or infected from the effects of your thick and painful toenails, then perhaps your care is routine and NOT covered. To add insult to injury, so to speak, if your care is NOT covered, then you have to sign a "waiver of liability", acknowledging that you have been informed of this. Medicare insists!
SO, what can YOU do about this?
I hope this is all perfectly clear. If not, perhaps Medicare would like to try explain it better. Inquiries, observations and complaints about the administration of Medicare in Connecticut can be directed to the currently, contracted Medicare carrier:
ATT: Medical Director
First Coast - Medicare Part-B
538 Preston Avenue
PO Box 9000
Wallingford, CT 06454-9000
If, for some reason, you feel that perhaps the regulations need to be changed, then call, WRITE or email your personal experiences and recommendations to your ELECTED, U.S. Congress people:
Click here to:
Communicate with your US
I know that each of them will be more than happy to hear from you, if nothing else. Their phone numbers and addresses are in the BLUE pages of the telephone directory, under "United States Government", 'United States Congress.'
So, please try to be understanding if your podiatrist says to you, "Unfortunately, your care today is NOT covered." You will have to pay for this caring, professional, podiatric care because Medicare doesn't.