Substitute Skin Graft Fraud

[MicroPod]

I just listened to a board meeting in a particular state that took place right after an oral exam I had to do in order to obtain a license in said state. They had a disciplinary meeting for a DPM who was excessively using substitute skin graft products on ulcer patients he was contracted with the VA for. I only heard the basics of the case, but he was tried and found guilty, and ultimately ordered to pay 7 million dollars to the United States. There are a couple of DPMs that we rotate with in our residency who use these exce$$ively (non VA patients), and I am just wondering when and if insurance companies will start nailing these guys as well. Thoughts?

---

Members don't see this ad.

 

[Adam Smasher]

From the title, I thought you were asking if we could substitute skin graft fraud with a different type of fraud. I still say pneumatic CAM boots are the single most efficient way to immobilize your way into early retirement.

 

[Feli]

MCR has already said they're not paying (cutoff date just got delayed) for the vast majority of these "substitutes."

Nearly all of them are crap with no EBM or maker-sponsored papers. I was fairly bored during covid and read a bit. There is really no EBM whatsoever. It's just a game to make $ for the product companies and the docs.

In the supergroup I briefly worked with, they'd sent lists of each doc's 'graft-eligible patients' (any wound pt with MCR plus secondary) to all associate DPMs... then tout the docs who had highest collections per visit (aka did most "grafts") to push others to follow suit. I did about zero of them. It was like they were giving out a sales commissions award for a car dealership or a timeshare company during the calls. It was wild.

...I would stay away from any facilities or groups or reps that push you to do certain stuff... particularly high pay stuff that doesn't make intuitive sense. The poor associates/employee DPMs are taking all of the risk here. In my group example, the associates get their 35% or whatever... and that is net after substantial cost of "grafts" themselves. So, basically the associates are risking fraud/overutilize with their NPI and doing something without EBM ... and for only a crummy 35/65% split or whatever. If the party's over and MCR or payers or whoever comes calling, you can bet that the employer/facility will absolutely dump all possible responsibility on the doc and say they didn't know what the docs and rep were doing.

The same logic follows for the bogus internal referrals for DME, testing, pharma, vasc, etc that promises big pay or kickback or whatever else for referring to where your employer owns or "arranged." If it doesn't make sense, tread very carefully - or just opt out. If it f***ks with your good medical decision making, then f**k it. Jmo.

...substitute skin graft fraud... ...pneumatic CAM boots ...

"...ain't the same ballpark, it ain't the same league, it ain't even the same f***in' sport. "

...There are 100s of legit and EBM uses for CAM boots.

 

[msion]

Oh this is nothing new. Insurances are looking at this already. They just don't tell you. But when they audit, get ready to submit 2 years of records of every patient. Medicare has multiples LCDs that called these products out.

The revenue stream from them will slowly dry up. Companies know this and that's why they are super ultra aggressive with the sales pitch now.

I can't think of a scenario where STSG is any inferior to these skin substitutes. Maybe the only times I use the substitutes are for venous stasis wounds.
But for most of the stuff we treat there should be always something else to look at: vascular, infection, surgically offloading such area, nutrition. Some placental membrane over a small ulcer on the PIPJs of contracted toes won't really do anything. Just cut the damn bone off. Same with the plantar met head ones.

And also those topical oxygen bags for wounds, OMFG.

 

[Feli]

Oh this is nothing new. Insurances are looking at this already. They just don't tell you. ...

Yep, I would say the biggest things to be careful with in podiatry office are

• fake skin subs, as described
• custom DME (done by either the office/group or store they own)... tons of issues with fraud (pt never even got it / was not made), over-utilizing (bilateral braces, DME out of DPM scope, etc), upcoding non-custom as custom, various other pitfalls.
• heavy testing (ABI, "biopsy" stuff, refer-for-profit to affiliated or quasi-affiliated vasc, PT, mri, etc), doing that stuff much more than peers.

The nerve stims will likely be there soon also. You don't want to be the tallest blade of grass on any of that stuff.

The podiatry cash services like laser or shockwave or cash wart tx and orthotics and lotions/potions and whatever are generally ok as they're surely over-utilized by most who own it... but they're also non-covered. Those will just cause customer service issues.

We will just see more and more of these types of things pop up as pod school grad numbers and debt burdens keep climbing.

...They should truly go after hospitals and wound centers for HBO on wounds also... does nothing except take many hours per week away from people who typically don't have very long left. Research shows that over and over. All they will try to tell you is, "this one plastic surgeon who used to go here saw good results." I've had pressure from every wound center or hospital ive been at or worked for to refer more HBO. That's junk.

...I can't think of a scenario where STSG is any inferior to these skin substitutes. ...

Yep, they're superior in most people. ^
In the very sick people where stsg aren't viable, the fake grafts won't do squat either... it's revasc if possible and prevent infection and just basic good wound care.

 

[Hybrocure]

I’m not a fan of in office skin subs, injectables, etc. The paperwork and charting is not worth the effort for me to do it kosher. And I have no experience doing it in ways that these people are supposedly raking big money off of doing illegally.

If it sounds too good to be true…it usually is

 

[heybrother]

I’m not a fan of in office skin subs, injectables, etc. The paperwork and charting is not worth the effort for me to do it kosher. And I have no experience doing it in ways that these people are supposedly raking big money off of doing illegally.

If it sounds too good to be true…it usually is

That's because you aren't getting the rebate.

 

[wakaflocka88]

Sorry graduating residency class of 2024, your job prospects are really more grim.

Major sad face to all our new fellowship trained wound gurus, looks like good old betadine and xeroform is your main weapon now.

 

[Hybrocure]

Sorry graduating residency class of 2024, your job prospects are really more grim.

Major sad face to all our new fellowship trained wound gurus, looks like good old betadine and xeroform is your main weapon now.

 

[Hybrocure]

That's because you aren't getting the rebate.

 

[Retrograde_Nail]

Oh this is nothing new. Insurances are looking at this already. They just don't tell you. But when they audit, get ready to submit 2 years of records of every patient. Medicare has multiples LCDs that called these products out.

The revenue stream from them will slowly dry up. Companies know this and that's why they are super ultra aggressive with the sales pitch now.

I can't think of a scenario where STSG is any inferior to these skin substitutes. Maybe the only times I use the substitutes are for venous stasis wounds.
But for most of the stuff we treat there should be always something else to look at: vascular, infection, surgically offloading such area, nutrition. Some placental membrane over a small ulcer on the PIPJs of contracted toes won't really do anything. Just cut the damn bone off. Same with the plantar met head ones.

And also those topical oxygen bags for wounds, OMFG.

I skin graft venous leg ulcers routinely.

 

[DYK343]

Grafts are dumb. Get your textbook out and figure out the biomechanical reason for the ulcer. 5-10 OR minutes later its cured and dont have an 80% recurrence rate.

Wound care providers throw these grafts on for $$$ only. Not patient benefit. $2k+ patient cost to be cured only to re-ulcerate 2 weeks later. What a scam.

Dumb.

STSG is the best treatment if/when biomechanics are addressed. And only if needed.

Close this chapter. Practice good medicine. Dont be a TFP.

 

[Hybrocure]

Grafts are dumb. Get your textbook out and figure out the biomechanical reason for the ulcer. 5-10 OR minutes later its cured and dont have an 80% recurrence rate.

Wound care providers throw these grafts on for $$$ only. Not patient benefit. $2k+ patient cost to be cured only to re-ulcerate 2 weeks later. What a scam.

Dumb.

STSG is the best treatment if/when biomechanics are addressed. And only if needed.

Close this chapter. Practice good medicine. Dont be a TFP.

Also STSG are rarely used in podiatry for what it’s worth. The only time I’ve ever seen it used successfully are on (somewhat) healthy younger patients with dorsal foot or lower leg wounds, usually drug or trauma related which don’t really fit the criteria for what we mostly see which is plantar sub 1st mtpj older unhealthy diabetic ulcers.

There’s definitely too many people grafting when you can just excise more tissue and close primarily.

 

[Retrograde_Nail]

Also STSG are rarely needed in podiatry for what it’s worth. The only time I’ve ever seen it used successfully are on (somewhat) healthy younger patients with dorsal foot or lower leg wounds, usually drug or trauma related which don’t really fit the criteria for what we mostly see which is plantar sub 1st mtpj older unhealthy diabetic ulcers.

There’s definitely too many people grafting when you can just excise more tissue and close primarily.

You are talking out of your ass.

Split thickness skin grafts are definitely utilized at a high rate for anyone doing significant amount of limb salvage. You don't know what you don't know. If you are not exposed to a high volume of wounds then you have no idea what it takes to get these wounds to heal. It's not as simple as a wound repair and call it good. Very rarely do those even work unless you got a compliant patient who will remain non weight bearing or they agree to be casted after said wound repair in clinic. Very rarely you are getting wounds that small to work with in the beginning.

I really don't know where you are coming from but its not coming from true experience.

I do STSG frequently to get closure over muscle flaps and complicated large wounds all over the foot, ankle and leg. I do it for burns. I do it for large venous leg ulcers which have failed everything.

 

[Hybrocure]

You are talking out of your ass.

Yes.

But also - you’re an outlier with what you do. The average podiatrist doesn’t have big LE burns walk in our door or are doing muscle flaps etc. The average podiatrist IS getting small/tiny wounds on a routine basis. This is why so many are abusing these skin subs and throwing them on everything unfortunately.

 

[Adam Smasher]

Time to incite a flame war.

I will agree that the doc billing $7M for grafts was clearly overusing them. Feli is right about not being the tallest blade of grass, put differently, don't fly too close to the sun.

I will also agree that it's abusive grafting over obvious biomechanical deficiencies, eg hallux ipj ulcer in pt with hallux rigidus.

But taking a strident position against the use of skin subs is painting with too broad of a brush. I have used them effectively in stalled wounds after I've ticked off all the other boxes. And I know my anecdotes don't trump your anecdotes so I'm not asking anyone to agree with me, just sharing my experience.

FACT: Skin subs definitely do something. Yes the studies are industry funded. As though people outside of industry don't have any axes to grind. None of the ortho papers suggesting dpms shouldn't do ankle surgery are industry funded.

FACT: if payers didn't want them to be used, they wouldn't reimburse them at all. Res ipsa loquitur.

FACT: insurance reimbursement are on a continual decline, while inflation is putting upward pressure on employee salaries. I don't have a cushy hospital set up, I have to pay my own staff. If any of you naysayers want to pool your resources and fund the definitive "grafts are bs" study, that's what you should do, otherwise I say live and let live.

To say that the use of skin subs is "unnecessary" is a quirky phraseology. They're necessary the same way bunion surgery and mycosis treatments are necessary. They're necessary the same way podiatry is necessary. Who wants to go down that rabbit hole?

FACT: a few years ago, I apligrafed a guy with a mediocre payer. The claims sat in limbo for a couple of months, then they reimbursed only one of the 44 units of Q4101. Took 6 months of appeals, and my profit ended up around $15. The apligraf cost $1300. That's a lousy 6 month ROI. That's an important reason I use skin subs so cautiously, payers will absolutely drag their feet on claims.

FACT: pneumatic CAM boots have a 600% markup, almost no paperwork, and never get questioned. To my knowledge, there's no EBM on the benefits of pneumatic vs non-pneumatic.🦞

 

[Retrograde_Nail]

Yes.

But also - you’re an outlier with what you do. The average podiatrist doesn’t have big LE burns walk in our door or are doing muscle flaps etc. The average podiatrist IS getting small/tiny wounds on a routine basis. This is why so many are abusing these skin subs and throwing them on everything unfortunately.

I have no doubt about it. I agree with this. But STSG def can be used routinely. I have no doubt that a lot of private practice podiatrists get dumped on with these nasty wounds just like I do even if it is not as frequent. There are opportunities to skin graft. Saying it’s rare is not correct. The training of each DPM varies. Some DPMs are just flat out greedy/lazy.

All these private practices have their own algorithms to max profits because they are so desperate to milk as much money as they can from patients.

 

[josebiwasabi]

I work out of a county hospital and frequently need to use both skin substitutes and STSG, probably 4-5 times a month for me. I have 3 other partners who likely do around the same volume.

I am pretty strict about my indications to apply a skin substitute and I have never had to apply more than 3 to the same wound. They must have adequately controlled a1c, at least dopplerable pulses, and failed offloading and standard of care wound care for 3 months. Most only require 1 or 2 applications total. Some of them have miraculous results. I commonly get referred stagnant non healing wounds for >6-12 months and I can get them epithelialized in a month or two.

 

[HeySister]

Also STSG are rarely used in podiatry for what it’s worth. The only time I’ve ever seen it used successfully are on (somewhat) healthy younger patients with dorsal foot or lower leg wounds, usually drug or trauma related which don’t really fit the criteria for what we mostly see which is plantar sub 1st mtpj older unhealthy diabetic ulcers.

There’s definitely too many people grafting when you can just excise more tissue and close primarily.

Yea this is an incorrect take. Probably regional based on your training. Most docs treating wounds surgically which is the right way, will use skin grafts

 

[Forcewielder]

Personally, I've seen good results with the skin subs. I do a fair amount of wound care and routinely get referred wounds others have worked on for over a year. I generally have the algorithm of weekly wound care using standard methods until healing stalls for 3 consecutive weeks and all other factors seem accounted for (granted, most of my patients refuse to NWB because I'm in a low income, rural area and people are as non-compliant as it gets). Once we get to that stage I run benefits and start skin subs. I can usually get stuff to heal with that. If they stall with those then we go to surgery. If they heal but then reopen later we go to surgery. We also can't do STSG at any of my facilities because we don't have a dermatome. Maybe there's a better way, but patients are happy, insurance reimburses well, and I don't feel like I'm doing anything remotely shady.

 

[heybrother]

These are from a lawsuit against Organogenesis that it looks like they won / got dismissed - but they are still cringe ie. if you saw people using Affinity / Puraply - ask yourself why.

 

[Retrograde_Nail]

These are from a lawsuit against Organogenesis that it looks like they won / got dismissed - but they are still cringe ie. if you saw people using Affinity / Puraply - ask yourself why.

View attachment 386770

View attachment 386771

View attachment 386772

I’ve used these products and they work pretty well. I work for a hospital in the wound care center so I get no extra profit from using them compared to private practitioners. I only get RVU credit. In my opinion the products work fine when indicated. Maybe private practitioners are billing fraudulently?

Does billing excessively and fraudulently for reimbursement make these particular products bad? Nope.

 

[heybrother]

I’ve used these products and they work pretty well. I work for a hospital in the wound care center so I get no extra profit from using them compared to private practitioners. I only get RVU credit. In my opinion the products work fine when indicated. Maybe private practitioners are billing fraudulently?

Does billing excessively and fraudulently for reimbursement make these particular products bad? Nope.

The lawsuit is not about fraudulent use. The people suing were shareholders in the company who felt they were mislead about the stock and the companies prospects which were driven by the behavior of people who used the product because of the "spread". Those same people presumably moved on when the spread didn't exist changing the share price. Hospital doctors are irrelevant - yes. You don't have a financial motivation to use the product and the hospital receives bundled payments (so its not like the hospital will beg you to use this or that product). This is to me just an interesting opportunity to look back on things you might have seen, but not understood. Old pods on a plural number of occasions said to me- everything in this profession is driven by reimbursement. I'd be at conferences wondering why were there so many graft companies or why were people pushing fungal nail PCR so hard. Because there was money to be made on it usually dinging Medicare.

 

[Adam Smasher]

This illustrates the difference between waste, fraud, and abuse.

• Fraud: you misrepresent what you did, and did it intentionally (example: bill 11730 on every pt in the nursing home)
• Abuse: you accurately represent what you did, but it was medically unnecessary, and did it intentionally (example: 10 affinities in a row)
• Waste: you accurately represent what you did, and it was medically unnecessary, but didn't do it intetionally (example: reordering labs because you didn't check the record)

I had to sit through a webinar on this a few months ago, while fraud is definitely bad, the powers that be are trying to crack down on abusive practices too. So overutilization of skin subs isn't fraud, it's just abuse. Different, but still bad

 

[p100]

It's just a game to make $ for the product companies and the docs.

This is off topic and not necessarily related to your post but I want to say the whole medical industry is a scam at this point. All the rules are made by people with the most fake money printed by the government. A few years ago I used to think it was so bad that these companies use loopholes and bribes to get paid by insurances and medicare but not anymore. As long as there is no harm to a patient I say squeeze insurance and medicare for everything they got. It is all fake fractional reserve money anyways and debt that will never get paid off.

Good for the docs that make as much as possible playing the game.

 

[Feli]

This is off topic and not necessarily related to your post but I want to say the whole medical industry is a scam at this point. All the rules are made by people with the most fake money printed by the government. A few years ago I used to think it was so bad that these companies use loopholes and bribes to get paid by insurances and medicare but not anymore. As long as there is no harm to a patient I say squeeze insurance and medicare for everything they got. It is all fake fractional reserve money anyways and debt that will never get paid off.

Good for the docs that make as much as possible playing the game.

I'm not sure.

The medical industry is largely a scam, yes... tons of unnecessary testing, billing, services.
However, I'm not sure on that meaning we all need to game the system as hard as we can.

I personally wish I had been a doc back in the day where people just paid what they can reasonably afford...
pt #1 ingrown nail pays two gold pieces,
pt #2 heel pain pays a wood chair he made,
pt #3 nail care is family and no pay needed,
pt #4 laceration repair is a hunter who can't pay today but will bring you some deer meat or something when they can,
pt #5 ingrown doesn't pay because she gives you that GP from time to time,
pt #6 pays for their kid's wart visit with some farm eggs and veggies,
pt #7 tendonitis gives you three gold pieces,
pt #8 skin lesion gives couple loaves of baked bread, etc.

Basically, before money, docs just charged the people in their village what they could reasonably afford... and it worked.

Money is just for large anonymous societies (basically a form of future favor/credit.. since trade/trust is no longer viable). I agree our money is now a scam... plentiful and rapidly inflated in amount / deflated in value. Maybe the USD will crash in our lifetime, and maybe it won't... but USA has air force and other places don't, so who would really call us out on it? We'd probably just make up the new USA digital dollar or whatever.

...I don't think we should hit insurances and MCR for all we can, though. Plenty of pods do DME and wound graft and other fraud, for sure. However, you can do fine without that, and you'll feel better about what you do if you treat patients like real people and how you'd want family treated. There is real negative psychology if you are almost literally trying to fleece people and their insurance, lol. Many of them do read EOBs. I have worked at a couple of those offices, and they get a bad rep quickly. It's also a risk that can turn out very badly to come out guns blazing on billing. I personally know a couple DPMs who are no longer practicing (DME fraud and other CPT fraud in surgery... both audited and kicked off MCR, had to find new careers), but more pods may be headed that way with the fake graft audits now in process. Some offices have already gone underwater financially with the clawbacks on fake grafts.

Basically, my first boss said - and is 100% right - that if insurances want docs to do more/less of certain things, they can just adjust the reimburse. Anyone can see the podiatry overall utilization of alcohol sclerosing injects or subtalar arthroeresis went waaaay down when payment was cut. Same for many other things. We will see that with fake wound grafts now. Similarly, if wart treatment or night splint or whatever pay tripled or even doubled, you'd suddenly see much more of it. Podiatry loves to find those "hot codes" (typically from another specialty) and hit the button until it breaks.

Overall, all docs will always be an easy target to give same/lower payments to because they are a relatively small group (voting or lobbying), they're viewed as rich, and they can't really negotiate much or go on strike or that's bargaining with human lives (aka "terrorist"). An auto body shop or a clothing store can just raise prices if their costs go up or if they're in demand, but our offices are paid by insurance... and we're pretty stuck on pricing.

Plus in podiatry specifically, you are double screwed because there are way too many of us, and another will always do the work for same/less pay. Specialties that control their saturation like Uro or Derm or Ortho can just laugh at bad fee schedules... podiatry usually has to take them.

 

[shadesofgrey]

I'm not sure.

The medical industry is largely a scam, yes... tons of unnecessary testing, billing, services.
However, I'm not sure on that meaning we all need to game the system as hard as we can.

I personally wish I had been a doc back in the day where people just paid what they can reasonably afford...
pt #1 ingrown nail pays two gold pieces,
pt #2 heel pain pays a wood chair he made,
pt #3 nail care is family and no pay needed,
pt #4 laceration repair is a hunter who can't pay today but will bring you some deer meat or something when they can,
pt #5 ingrown doesn't pay because she gives you that GP from time to time,
pt #6 pays for their kid's wart visit with some farm eggs and veggies,
pt #7 tendonitis gives you three gold pieces,
pt #8 skin lesion gives couple loaves of baked bread, etc.

Basically, before money, docs just charged the people in their village what they could reasonably afford... and it worked.

I was at a conference a few years ago and was talking to a pod that practiced in rural Alaska. It sounded like it was mainly RFC and wound care, but she said she routinely bartered her services. I distinctly remember her talking about getting paid with fresh Salmon. Not saying its necessarily related, but she was one of the happiest pods I've been around.