2011 Apmsa

2 0 1 1
APMSA
NEW
PRACTITIONERS
GUIDE
When they come to you ...
1
RITA. Research and Innovative Technology Administration, Bureau of Transportation
Statistics.http://www.transtats.bts.gov/Oneway.asp? Display_Flag=0&Percent_Flag=0.
Accessed Aug 24, 2010.
Instant Coupon available at www.NaftinCoupons.com
or by calling 1 888 296 1852
Indication
Naftin
(naftine HCl 1%) Cream and Gel are indicated for the topical
treatment of tinea pedis, tinea cruris and tinea corporis caused by Tricho-
phyton rubrum, Trichophyton mentagro phytes, Epidermophyton occosum
and Trichophy ton tonsurans (Gel only).
Important Safety Information
Naftin
Cream and Gel are contraindicated in individuals who have shown

hypersensitivity to any of their components and are for topical use only.
The most commonly reported side effects of Naftin
are burning/stinging,
dryness, redness, itching, and local irritation.
Many eligible patients will receive the Naftin 90gm
size at No Out-of-Pocket Cost!**
Please see adjacent page for Full Prescribing Information
UP TO $100 OFF
*

INSTANTLY FOR ANY
NAFTIN (naftine HCl 1%)
sG0UMP
sG#REAM
sG'EL2XPRODUCT
* Subject to eligibility. Restrictions apply.
** Average co-pay shown veried as of August 2010 based on
reports from 380 health plans (eg. HMO, PPO, IPA, etc.) inclusive
of all benet designs/co-pay tiers.
On average, over 20 million people will board airplanes each month around the world.
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Some will walk barefooted through airport security which may expose them to tinea pedis.
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Now that you have completed your residency, you are responsible for .
A.) Taking a long, leisurely vacation.
B.) Having a life again.
C.) Making sure you have the proper malpractice
insurance coverage before you see a patient.
Podiatry Insurance Company of America (PICA) was founded by podiatrists, for podiatrists over 30
years ago. PICA is podiatry-focused and the nations top podiatric malpractice insurance provider.
We are endorsed by APMA and offer generous new practitioner discounts. PICA, however, cannot
provide accommodations for a long vacation or assist you with your social calendar.
One Last Quiz
For all of your malpractice insurance needs, visit us online at picagroup.com or call
(800) 251-5727 option 3, option 2.
1
RITA. Research and Innovative Technology Administration, Bureau of Transportation Statistics.http://
www.transtats.bts.gov/Oneway.asp? Display_Flag=0&Percent_Flag=0. Accessed Aug 24, 2010.
or by calling 1 888 296 1852
Indication
Naftin
(naftine HCl 1%) Cream and Gel are indicated for the topical treatment of tinea
pedis, tinea cruris and tinea corporis caused by Trichophyton rubrum, Trichophyton
mentagro phytes, Epidermophyton occosum and Trichophy ton tonsurans (Gel only).
Naftin
Cream and Gel are contraindicated in individuals who have shown hypersensitivity
to any of their components and are for topical use only. The most commonly reported side
effects of Naftin
are burning/stinging, dryness, redness, itching, and local irritation.

UP TO $100 OFF
*

INSTANTLY FOR ANY
sG0UMP
sG#REAM
sG'EL2XPRODUCT
** Average co-pay shown veried as of August 2010 based
on reports from 380 health plans (eg. HMO, PPO, IPA, etc.)
inclusive of all benet designs/co-pay tiers.
1

Rx ONLY
INDICATIONS AND USAGE: Naftin
Cream, 1% is indicated for the topical

treatment of tinea pedis, tinea cruris, and tinea corporis caused by the organisms
Trichophyton rubrum, Trichophyton mentagrophytes, and Epidermophyton floccosum.
Naftin
Gel, 1% is indicated for the topical treatment of tinea pedis, tinea cruris,
and tinea corporis caused by the organisms Trichophyton rubrum, Trichophyton
mentagrophytes, Trichophyton tonsurans*, Epidermophyton floccosum*.
* Efficacy for this organism in this organ system was studied in fewer than
10 infections.
CONTRAINDICATIONS: Naftin
Cream and Gel, 1% are contraindicated in individuals

who have shown hypersensitivity to any of their components.
WARNINGS: Naftin
Cream and Gel, 1% are for topical use only and not for
ophthalmic use.
PRECAUTIONS: General: Naftin
Cream and Gel, 1%, are for external use only.

If irritation or sensitivity develops with the use of Naftin
Cream or Gel, 1%, treatment

should be discontinued and appropriate therapy instituted. Diagnosis of the disease
should be confirmed either by direct microscopic examination of a mounting of
infected tissue in a solution of potassium hydroxide or by culture on an appropriate
medium.
Information for patients: The patient should be told to:
1. Avoid the use of occlusive dressings or wrappings unless otherwise directed by
the physician.
2. Keep Naftin
Cream and Gel, 1% away from the eyes, nose, mouth and other
mucous membranes.
Carcinogenesis, mutagenesis, impairment of fertility: Long-term studies to
evaluate the carcinogenic potential of Naftin
Cream and Gel, 1% have not been

performed. In vitro and animal studies have not demonstrated any mutagenic effect
or effect on fertility.
Pregnancy: Teratogenic Effects: Pregnancy Category B: Reproduction studies
have been performed in rats and rabbits (via oral administration) at doses 150 times
or more than the topical human dose and have revealed no evidence of impaired
fertility or harm to the fetus due to naftifine. There are, however, no adequate and
well-controlled studies in pregnant women. Because animal reproduction studies are
not always predictive of human response, this drug should be used during pregnancy
only if clearly needed.
Nursing mothers: It is not known whether this drug is excreted in human milk.
Because many drugs are excreted in human milk, caution should be exercised when
Naftin
Cream or Gel,1% are administered to a nursing woman.

Pediatric use: Safety and effectiveness in pediatric patients have not been
established.
ADVERSE REACTIONS: During clinical trials with Naftin
Cream, 1%, the incidence

of adverse reactions was as follows: burning/stinging (6%), dryness (3%), erythema
(2%), itching (2%), local irritation (2%). During clinical trials with Naftin
Gel, 1%,
the incidence of adverse reactions was as follows: burning /stinging (5.0%), itching
(1.0%), erythema (0.5%), rash (0.5%), skin tenderness (0.5%).
GEL CREAM
Manufactured for Merz Pharmaceuticals, Greensboro, NC 27410
2010 Merz Pharmaceuticals Rev 3/10
BRIEF SUMMARY
APMSA
New
Practitioners
Guide 2011
Cover design services were provided through the
generosity and support of the Podiatry Insurance
Company of America (PICA) by graphic designer
Vanessa Multon.
Advancing Podiatric Medicine
Through Excellence and Unity
Editor Dorothy Cahill McDonald
APMSA Class of 2011 Delegates
Lindsey Calligaro NYCPM
Mark B. Ellis CPMS
Zackary B. Gangwer AZPOD
Blair Jolley TUSPM
Lena Keester SCPM
Charles Lee NYCPM
Lucinda Malvitz SCPM
Brian Oase AZPOD
Derek Pantiel OCPM
Patrick Qualtire CSPM
Jasmaine Shelford BUSGM
As an APMA Member, you qualify for
a multitude of benefits including:
O Marketing Tools for your practice
including the Footprints newsletter
and PowerPoint presentations, all
customizable and free of charge
O PR Tools including press releases
and office brochures
O Access to the Coding Resource Center
O APMA News and The Journal
of the APMA
O Reduced pricing to attend
The National, APMAs annual
scientific meeting
For more information or to speak directly to a Membership Specialist, please contact APMA at:
1-800-ASK-APMA or www.apma.org
Your
Benefits
Abound
Dedication
Te APMSA 2011
New Practitioners Guide
is dedicated to the
accomplishments,
past and future,
of the podiatric medical
student class of 2011.
To furnish the means of acquiring
knowledge is... the greatest beneft
that can be conferred upon mankind.
It prolongs life itself and enlarges the
sphere of existence.
John Quincy Adams
Performance is our heritage, commitment, and the force behind New Balance Total Fit. New Balance personally
selects dealers with the proper expertise and an extensive selection to ensure you get the right shoe and right t for
your active lifestyle. Find a Procare dealer near you now: newbalance.com/shop/procare
Shoes That Fit Better
PERFORM BETTER
2011 All rights reserved.
APMSA 2011 .indd 1 2/2/11 4:20 PM
From the Editor
Congratulations to the class of 2011 on the successful completion of
your degree in podiatric medicine, and to those beginning to navigate
the journey into the practice of podiatric medicine. We trust that this
publication will serve as a valuable resource for you during residency
and in the frst few years of practice.
I extend my sincere appreciation to the following individuals and
organizations for their advice, support and contributions to the
APMSA 2011 New Practitioners Guide.
Susan Austin
APMA Staff and Board of Trustees
Meredith Church
Jo Deckert
Mary Jane Dorr
Jackie Hardy
Vanessa Multon
Podiatry Insurance Company of America (PICA)
Teresa Russell
To my family, Jr., Grace, Meredith, and Shane, I am so blessed
that you are mine.
Dorothy Cahill McDonald
Editor
APMSA Executive Director
Spenco_APMSA2011_out.pdf 3/1/11 9:53:20 AM
Advancing Podiatric Medicine Through Excellence and Unity
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For over 25 years, the APMSA Corporate Advisory Board (CAB) has supported the APMSA and
podiatric medical students. The APMSA is grateful to the following APMSA CAB members who
have supported a broad range of student programs and projects including the APMSA New
Practitioners Guide and the APMSA Residency Survey:

For over 60 years, Aetrex has pioneered the application of pedorthic expertise to high
performance foot care products and technologies. Aetrex offers doctors unique products that
truly address the specific needs of their patients. The Aetrex development team includes over 25
certified pedorthists. Aetrex proudly supports the American Podiatric Medical Students
Association and looks forward to working with all graduates throughout their career.

ASICS is an acronym derived from the Latin phrase Anima Sana In Corpore Sano - a sound mind
in a sound body. Staying true to this philosophy, every ASICS innovation, concept, and idea is
intended to create the best athletic products. We pledge to continue to make the best product;
striving to build upon our technological advances and pushing the limits on what we can learn
from the body and its needs in athletic gear. We pledge to bring harmony to the body and soul.

Bako Podiatric Pathology Services is a physician-owned provider of a wide array of pathology
services ranging from histopathologic examination of bone, soft tissue, and skin/nail unit, to
microbiology and epidermal nerve fiber density testing. We pride ourselves on providing the best
available customer service, concise reports with therapeutic options, photomicrographic imaging,
compliant and patient-friendly billing policies, internet-based report access, and a client/patient
comes-first business model. At Bako Pathology Services, we're not just providing a premium
pathology service; we're dedicated to the advancement of this great profession through
Education, Research, and Financial Support. 877-DPM-PATH www.bakopathology.com

Crocs Footwear has become a bona-fide phenomenon, universally accepted as an all purpose
shoe for comfort and fashion. Despite our rapid success, we still stand behind the core values of
Crocs Footwear. We are committed to making a lightweight, comfortable, slip-resistant,
fashionable and functional shoe, which can be produced quickly and at an affordable price to our
customers. We thank you for your support and look forward to providing you with exciting new
Crocs Shoe designs in the years to come.

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In 2010, DARCO International, Inc. is celebrating its 25
th
year as a leading provider of post op,
trauma and wound care solutions to the global foot and ankle community. DARCOs reputation
is founded on the unyielding pursuit of developing innovative, high-quality products that bring
exceptional value to the podiatric practitioners and their patients. Since the beginning, DARCO
has been a loyal supporter of the podiatric profession.

Gill Podiatry Supply and Equipment Company is solely dedicated to providing products and
services to the podiatrist. Were a full service company that offers quality products at
competitive prices. We offer one-step shopping carrying all the instruments, supplies and
equipment you need. Gills professional staff is available to advise and assist you in making your
purchases. Whether your purchase is a single item, class purchase or setting up your entire
office, Gill is there to help you. 800-321-1348; www.gillpodiatry.com.

Gordon Laboratories has been a member of CAB since its inception in 1985. The company has
played an integral role in podiatry since manufacturing the first topical pharmaceutical product
line for the profession more than a half century ago. Today the company manufactures the
largest selection of quality podiatric pharmaceuticals for all types of topical conditions. Gordons
ongoing commitment to the profession includes: in-office dispensing assistance,
educational/scholarship aid, and funding for student projects.

Biofreeze Pain Reliever is the most frequently used and #1 recommended topical pain reliever by
hands-on healthcare professionals. For over 18 years, Biofreeze products have been helping
people mange their discomfort by offering a variety of benefits that assist in exercise/training,
pain relief, therapy and overall comfort. Using natural menthol as the active ingredient, Biofreeze
products act quickly, helping to prevent or relieve pain. www.biofreeze.com 800-246-3733.

Since 1969 Langer Biomechanics, Inc. has upheld a reputation as a leading manufacturer of
lower extremity care products, including custom orthotics, ankle foot orthoses, Durable Medical
Equipment and PPT. We are confident that our experienced staff and constantly evolving product
line will provide patients with the highest quality care possible. We are committed to ensuring
positive patient outcomes and still adhere to the belief that practitioners are dedicated to
providing what is best for their patients. Langer is honored to work with the APMSA and looks
forward to serving as both an educational resource and provider of high quality orthopedic
products.

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Moore Medical, LLC is a leading distributor of medical-surgical supplies, equipment, furniture and
pharmaceuticals in podiatry that has been serving the industry for over 60 years. Our
experienced podiatry team includes sales and market specialists who understand your needs and
are constantly searching for new and better solutions to help you succeed. Moore Medical has
over 15,000 products available through our national distribution network including over 1,200 in
our exclusive Moore Brand product line. Empowering you with the supplies, tools, information
and resources you need to support the health and care of your patients - and your business -
is our main purpose. Over 100,000 health care professionals nationwide trust Moore Medical as
a partner and a valued resource. Call us at 800.234.1464; or visit: www.mooremedical.com.

Privately held Boston-based New Balance has grown from a small company to an industry leader
in both footwear and apparel by remaining committed to teamwork, technological innovation,
width-sizing, domestic manufacturing, grassroots promotions, and strong retailer partnerships.
Footwear product categories include running, cross-training, walking, tennis, adventure sports,
team and kids. New Balance also supports a family of brands including Aravon, Dunham, PF
Flyer, Warrior and Brine.

Pedinol Pharmacal Inc. would like to congratulate podiatry school graduates of 2009 on
completing their podiatric medicine education. As a podiatry specific pharmaceutical company
since 1925, Pedinol is excited to have you join the profession of podiatric medicine. We look
forward to providing you and your patients with safe and effective treatments. Please visit us at
www.pedinol.com. Congratulations and best of luck from everyone at Pedinol!

Podiatry Insurance Company of America (PICA) is the nation's leading provider of professional
liability insurance for podiatric physicians. We offer excellent new practitioner discounts with no
finance charges for newly practicing doctors. We support your profession with scholarships for
students and sponsorship of the APMSA and APMA Young Members' Program. In addition, we are
endorsed by the APMA and the ACFAS.

PRESENT e-Learning Systems is dedicated to improving the knowledge and skills of medical
professionals throughout the world by providing high quality medical education programming via
the Internet and by fostering collaboration with their peers at worldwide centers of excellence.
www.presentelearning.com

ProLab Orthotics is an orthotic industry leader, incorporating evidence-based medicine and
clinical expertise into our orthotic design for optimal patient outcomes. Partner with ProLab for
exceptional products, free clinical consultations with our team of podiatrists, and to access our

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extensive scientific and educational resources. For more information, call (800)477-6522 or go to
www.prolaborthotics.com.

Promet has been making custom foot orthotics for podiatry since 1992. Promet is owned and
operated by founder Dave Krueger, a Certified Pedorthist and University of Minnesota graduate,
with an extensive background in orthopedic footwear and athletics. Our staff is a crew of highly
experienced and talented technicians who have demonstrated great loyalty to our company and
our customers in our sixteen years of service. Our devices will be made exactly the way you
want them, or we can suggest a device that will fit your needs.

Nature intended us to be barefoot. However, we need shoes to protect our feet. The next best
thing to barefoot is a good comfortable shoe. SAS creates each new shoe with only one thing in
mindyou. We could use cheaper materials - but youd feel the difference. We work overtime
working out comfort issues because your day doesnt always end at 5. Obsessive? Maybewe
historically take the hard road so you dont have to. www.SASshoes.com.

Straight Arrow Products, Inc., are the providers of unique therapeutic skin care products, such as
Foot Miracle, Urea Care and Hoofmaker, that have garnered a loyal following in the
podiatric world over twenty years. www.straightarrowinc.com.

Swede-O, Inc has been recognized the worldwide leader in providing innovative products
designed to prevent or rehabilitate ankle related injuries for over 25 years. Numerous
independent clinical studies have proven the effectiveness of Swede-O ankle braces in preventing
ankle injuries and that they are equal to or better than professionally applied tape for ankle
support. We recently expanded our product offerings to include a patented line of orthopedic
supports designed to prevent, treat and rehabilitate most any part of the body. Swede-O
remains the first choice for ankle protection.

Upsher-Smith is pursuing improved drug therapies to improve peoples lives. The evolution of our
company is driven by the ever-changing needs of patients, physicians, pharmacists, and
healthcare organizations. Our perspective is not more products, but the right products that
make peoples lives better. At every level of our business, we are driven to be the best. We
promise to provide reliable, affordable products that have a daily impact to improve lives.

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APMSA 2011 NEW PRACTITIONERS GUIDE

TABLE OF CONTENTS PAGE

I. PRACTICE PREPARATION/GETTING STARTED 17

A Message from the APMA 19
APMA Young Member Membership 22
APMA State Component Associations 27
APMA Affiliated and Related Organizations 36
Pre-Practice Preparation Checklist 40
Drug Enforcement Agency Information 46
National Provider Identifier 48
State Licensing Terms/Resources/Scope of Practice 55
State Licensing Information and Requirements 59

II. DEBT MANAGEMENT 81

Navigating the Repayment Process 83
Your Rights and Responsibilities 84
Loan Programs 86
Repayment Strategies 91
Selecting a Financial Advisor 103
Resources/Definition of Terms and Conditions 108

III. GOVERNMENT REGULATIONS 119

Security Policies and Procedures The Final Hurdle 121
Taking the Mystery Out of OSHA 126
Electronic Medical Records 130
E-Prescribing 131
APMA Coding Manual and Medicare Resources 132

IV. PRACTICE OPTIONS, MANAGEMENT & RESOURCES 135

Practice Options and Management 137
Opening a Podiatry Practice 142
Motivating Your Staff 154
How to Connect With a New Patient in Sixty Seconds 156
Give Your Patient a Pound of Gold in a One-Ounce Bag 158
Customer Service and Continuous Quality 163
Improvement to Enhance Patient Care
How to Step up Assistant Efficiency 168
APMA Private Insurance Resource Guide 171

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V. PODIATRIC MARKETING 175

Practical Marketing Tips for Private Practice 177
Enhancing Your Patient Relations - The Many Uses 183
of a Practice Brochure
Establishing a Broad Patient Referral Base 187
Winning the Physician Referral Game 195
Strategies for Internal Marketing of Your Practice 202
The Essentials of Web Site Marketing 209

VI. ESTABLISHING AND BUYING A PRACTICE 211

Financing a Podiatric Practice 213
Five Common Myths of New Practitioners 214
The How, When, Where and Why of Associates and Buy-ins 218
Factors to Consider in Compensating a New Associate 224
Buying and Selling a Medical Practice 227
More Than Money 233
Employment Agreement 234

VII. INSURANCE 239

Insurance for the New Practitioner 241
Insurance Action Plan 248
Malpractice Insurance: What You Should Know 251

VIII. OFFICE SUPPLIES AND SET-UP 253

Podiatric Supplies 257
Top Ten Ways to Improve Exam Room Efficiency 261
Office Furnishings and Supply Costs 262
Medical Equipment for the New Practitioner 263

IX. DURABLE MEDICAL EQUIPMENT AND ORTHOTICS 265

Durable Medical Equipment, Prosthetics, Orthotics, and Supplies 267
In-Office Dispensing 269
Orthotic in Your Practice 271
Getting Started with Orthotics 272
Orthotic Tips 274
Making the Most of the Medicare Therapeutic Shoe Program 275

INDEX OF ADVERTISERS 279

INDEX OF APMSA CORPORATE ADVISORY BOARD (CAB) 10

I.
Practice
Preparation/
Getting Started
American
Society of
ASPS
Podiatric
Surgeons
An affiliate of APMA
Free Membership
for Students and
Residents
The American Society of Podiatric Surgeons
(ASPS) is proud to recognize the value and
unique needs of students and residents by
offering free membership.
ASPS also recognizes the challenges facing
new podiatric surgeons by offering value-
added discounted dues for young members.
Join APMAs surgical affiliate and become
a part of an organization that is defining
the future for podiatric surgeons and others
interested in foot and ankle surgery.
G Enjoy complimentary registration to ASPS work-
shops and seminars.
G Gain access to the ASPS member-exclusive online
education resource, ASPS University.
G Benefit from an affordable dues structure, including
free dues for students and residents and significantly
discounted dues for young members.
G Gain access and information about the highest-qual-
ity continuing podiatric medical education programs
related to surgery.
G Help influence the future of the profession.
Why ASPS?
To learn more about
ASPS and apply online,
visit the ASPS Web site
www.aspsmembers.org.
real world
a T
The American Board of Podiatric
Orthopedics and Primary Podiatric Medicine
(ABPOPPM) is one of only two certifying
boards recognized by the American
Podiatric Medical Association. The
ABPOPPM conducts a board certification
process in the specialty of Podiatric
Orthopedics and Primary Podiatric
Medicine. It represents the specialty
concerned with providing comprehensive
primary podiatric medical care...the specialty
encompassing at least eighty percent of
practice activity in most successful podiatric
practicesthe specialty that represents the
of podiatric practice.
Podiatric Orthopedics and Primary
Podiatric Medicine integrates the biological,
biomechanical, rehabilitative, clinical and
behavioral sciences and encompasses first
contact and continuous care in general
podiatric practice.
The Council on Podiatric Medical
Education (CPME), through its Joint
Committee on the Recognition of Specialty
Boards (JCRSB), authorizes the ABPOPPM
to qualify and certify podiatric medical and
orthopedic expertise. The ABPOPPM also
has ongoing representation and
membership on the Joint Residency
Review Committee of the CPME in the
development of requirements for podiatric
residency education and in the evaluation
of residency training programs, thus both
defining and assessing compliance with
the competencies established by this
board for residency education.
Board certification by the ABPOPPM
provides assurance to the general public,
as well as to the medical community, that
you have been judged by your peers to
have demonstrated through a rigorous
examination and peer review process a
level of professionalism as a genuine
specialist in your field enhancing the
credibility of your existing credentials and
promoting your professional image.
The ABPOPPM certificate is time-
tested. Join an organized tradition of
excellence in Podiatry.
ABPOPPM Certification
radition of Excellence in our Profession
The American Board
of Podiatric Orthopedics
and Primary Podiatric Medicine
3812 Sepulveda Boulevard, Suite 530
Torrance, CA 90505
Phone: (310) 375-0700 Fax: (310) 375-1386
www.abpoppm.org
Congratulations to the Class of 2011 from
APMAs Young Members Program
PUTTING THE
PIECES TOGETHER
FOR YOUR SUCCESS!
The Young Members Program serves the needs and
interests of the APMA Young Members (students,
post-graduates, and young practitioners with four
years or fewer of practice).
By joining APMA you automatically become a
member of the Young Members Program.
FREE APMA Membership for
first year residents
APMA Young Members Salary and
Benefits Assessment
Tailored track of lectures/seminars during
the APMA Annual Scientific Meeting and
regional meetings
Complimentary registration for the APMA
Annual Scientific Meeting for student and
resident members
Discounted registration fees for
Podiatry Institute Seminars
JOIN APMA TODAY
AND TAKE AN
ACTIVE INTEREST
IN YOUR FUTURE
AND YOUR ASSOCIATION!
Podiatry Insurance Company of America,
the founding partner of the Young Members Program
Contributing partners of the Young Members Program
More Podiatrists
are choosing
GILL PODIATRY
for their equipment and
supplies everyday!
More Podiatrists
are choosing
GILL PODIATRY
for their equipment and
supplies everyday!
PODIATRY SUPPLY
& EQUIPMENT CO.
22400 Ascoa Court StrongsviIIe, OH 44149-4766
25

Joining the American Podiatric Medical Association

APMA recognizes that residents have unique concerns deserving special attention. We
understand that the health care environment you encounter is constantly changing,
sometimes unpredictable, and often confusing. APMA has multiple resources for residents,
and your APMA membership gives you direct access to all of these:

Publications: APMA News, our twice-weekly digital News Brief, and the Journal of the
American Podiatric Medical Association

Exclusive members-only content on our website
APMA HIPAA Privacy Manual and APMA HIPAA Security Manual
APMA State Reference Manual
APMA Hospital Privileging and Credentialing Resource Guide
APMA Coding Resource Center
APMA Private Insurance Resource Guide
APMA Insurance Complaint Survey
APMA Medicare Compliance Manual

Educational tracks at the APMA Annual Scientific Meeting

Practice marketing tools, including PowerPoint presentations, APMA apparel, decals,
membership certificates, downloadable APMA logos, and a customizable
member/patient informational newsletter

Membership in your professional association is an important part of your postgraduate
training and future success. This is why APMA is offering all DPMs in their first year
of residency training national membership at NO CHARGE!

The process is easy!

Complete the abbreviated membership application included in this graduation
handbook. Please complete all areas. An incomplete application can delay
processing.

Mail the completed application to APMA. The postage is prepaid for your
convenience. Your application will be processed as soon as possible, and your
APMA benefits will start immediately.

Because dual membership with the state component is required, APMA will forward a
copy of your application to the appropriate state component.

Let APMA help you begin your career equipped with the best possible resources available to
the podiatric physician. For more information, contact APMA membership services at 800-
ASK-APMA.

BlOFREEZE HELPS RELlEVE
FOOT & ANKLE DlSCOMFORT
Patints may hav challnos in rachino ano tratino thir
t. Hlp thm rouc th pain by rcommnoino on o th
Piorz
Pain Rlivino Vips, Spray, Roll-On, or th Gl with

Hanos-Fr /pplicator.
Encourao your patints to trat thir symptoms at hom by
applyino Piorz to th acto aras. Piorz provios a
coolino, soothino rli, ano you can rcommno Piorz as
ao|unct to othr tratmnts.
Now your patient has many options to
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Finally...
CALL YOUR DISTRIBUTOR TO ORDER YOUR
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TM
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therapy
Thera-Band Resistance Band for stretching
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Biofreeze
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temporary relief of foot pain
Easy-to-follow instructions for an at-home
treatment plan
For HeeI Pain
Equip your patients with practical tools they
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30
27
State Component Associations and Societies - March 2011
* Indicates the membership contact. For updated information visit:www.apma.org/statecomponents

Alabama Podiatric Medical Association - http://alapma.org
Kent Martin, DPM, President
426 Cox Blvd.
Sheffield, AL 35660
Phone: 256-389-1990

*Debbie Hancock, Executive
P.O. Box 81
Locust Fork, AL 35097
Phone: 205-680-5518

Alaska Podiatric Medical Association
*Kenneth Swayman, DPM, President
2741 Debarr Rd., #C-315
Anchorage, AK 99508
Phone: 907-562-4958;
kswaymandpm@yahoo.com

Arizona Podiatric Medical Association
Mark Forman, DPM, President
8585 E. Bell Road #A101
Scottsdale, AZ 85260
Phone: 480-423-8400
Spencer Niemann, DPM, Secretary
444 W. Osborn Rd. #301
Phoenix, AZ 85013
Phone: 602-264-1031

Arkansas Podiatric Medical Association
Richard Alex Dellinger, DPM, President
3 Athena Ct.
Little Rock, AR 72227
Phone: 501-350-3088
*Angela Pinkston-Ayson, DPM,
11 Halsted Cir. #E
Rogers, AR 72756
Phone: 479-636-3668/ 888-396-3668

California Podiatric Medical Association http://www.calpma.org/
Michael Cornelison, DPM,
President
10353 Torre Avenue #C
Cupertino, CA 95014
Phone: 408-446-5811
Fax: 408-996-1637
Jon Hultman, DPM, Exec Director
2430 K St., Suite 200
Sacramento, CA 95816
Phone: 916-448-0248
jhultmaned@podiatrists.org

Colorado Podiatric Medical Association - www.colopma.org
Frederick Mechanik, DPM, President
P.O. Box 422
Fountain, CO 80817
Phone: 719-526-7435
Fax: 719-526-7377
*Anne-Marie Zuccarelli, Exec Dir.
3080 S. Fulton Court
Denver, CO 80231
303-881-8837; maxamz@aol.com

28
Connecticut Podiatric Medical Association
Marc Lederman, DPM
President & Executive Director
2531 Albany Ave.
West Hartford, CT 06117
Phone: 860-236-2564

*Eva Storrs, Association Manager
342 N. Main Street
West Hartford, CT 06117
Phone: 860-586-7512
Estorrs@cpma.org

Delaware Podiatric Medical Association
Jason Kline, DPM, President
2600 Glasgow Avenue #107
Newark, DE 19702
Phone: 302-834-3575

Christopher Savage, DPM, Exec Dir.
1010 N. Bancroft Pkwy.
Wilmington, DE 19805
Phone: 302-658-1129

DC Podiatric Medical Association - http://www.dcpma.org
Howard Osterman, DPM, President
8630 Fenton St., #1
Silver Spring, MD 20910
Phone: 301-587-5666
Fax: 301-589-4479
Ken Silverstein, Ex. Dir.
17825 Sandcastle Ct.
Olney, MD 20832
Phone: 301-260-9700
kslvrstein@aol.com

Federal Services Podiatric Medical Association
*Joyce Kubu, APMA Membership Services Rep
9312 Old Georgetown Rd.
Bethesda, MD 20814
Phone: 301-581-9273/800-ASK-APMA, ext. 273
jfkubu@apma.org
Gene Goldman, DPM, President
8500 Marsh Point Dr.
Montgomery, AL 36117
Phone: 334-356-1959
Jack Bois, DPM
2409 Fairoak Ct.
San Jose, CA 95125
Phone: 650-493-5000, ext.
64922;jbois@webbox.com

Florida Podiatric Medical Association - www.fpma.com
Robert Iannacone, DPM, President
691 SW Port St. Lucie Blvd.
Port Saint Lucie, FL 34953
Phone: 772-878-0040
Fax: 772-878-4265
Michael Schwartz, Ex. Dir.
410 N. Gadsden St.
Tallahassee, FL 32301
Phone: 850-224-4085 or 800-277-3338
mschwartz@fpma.com

Georgia Podiatric Medical Association - http://www.gapma.com/
Sarvepalli Jokhai, DPM, President
204 Pinnacle Ct.
Macon, GA 31206
Phone: 912-475-9968

*Wesley Daniel, DPM, Ex. Dir.
1975-B Beverly Rd.
Gainesville, GA 30501
Phone: 770-536-9908

29
Hawaii Podiatric Medical Association
Gregory Morris DPM, President
1329 Lusitana St. #802
Honolulu, HI 96813
Phone: 808-528-4144
Fax: 808-525-6868
*Tyler Chihara, DPM, Treasurer
3-3420 Kuhio Hwy. #B
Lihue, HI 96766
Phone: 808-245-1523
chihara@hawaiilink.net

Idaho Podiatric Medical Association
Randal Wraalstad, DPM, President
562 Shoup Ave., W
Twin Falls, ID 83301
Phone: 208-734-3455
Fax: 208-733-7389
*Connie Searles, Exec. Dir.
270 N. 27th St., #B
Boise, ID 83702
Phone: 208-345-3072
ipma@qwestoffice.net

Illinois Podiatric Medical Association - www.ipma.net
Marlene Reid, DPM, President
640 S. Washington Street #240
Naperville, IL 60540
Phone: 630-355-4336
Fax: 630-355-3016
Mary Feeley, Exec. Dir.
122 S. Michigan Ave., #1441
Chicago, IL 60603
Phone: 312-427-5810
msfeeley@ipma.net

Indiana Podiatric Medical Association
Jane Koch, DPM, President
4640 W. Lloyd Expressway
Evansville, IN 47712
Phone: 812-422-4336
Fax: 812-421-0991
*Ginny Jewell, Exec. Dir.
101 W. Ohio St., #780
Indianapolis, IN 46204
Phone: 317-222-3847
inpma@indianapodiatric.org

Iowa Podiatric Medical Association -www.ipms.org
Eugene L. Nassif, Jr., DPM
1215 Blairs Ferry Rd.
Marion, IA 52302
Phone: 319-363-8854

Kevin Kruse, Executive Director
525 S.W. 5th St., #A
Des Moines, IA 50309
Phone: 515-282-8192

Kansas Podiatric Medical Association
Warren Abbott, DPM, President
PO Box 67143
Topeka, KS 66667
Phone: 785-273-3500

*Scott McKenzie, Exec. Dir.
1603 S.W. 37th St.
Topeka, KS 66611
Phone & Fax: 785-267-5400
smac52@sbcglobal.net

Kentucky Podiatric Medical Association - info@kypma.org
Ann Farrer, DPM, President
2148 Ami Lane
Lexington, KY 40516
Phone: 859-299-8646
John Underwood, Ex. Dir.
1501 Twilight Trail
Frankfort, KY 40601
Phone: 502-223-5322
30

Louisiana Podiatric Medical Association
Amy Schunemeyer-Prudy, DPM, Pre.
521 N. Lewis Avenue #A
New Iberia, LA 70560
Phone: 337-365-70560

*Mack Jay Groves, DPM, Treasurer
802 W. 10
th
Avenue #2
Covington, LA 70433
Phone: 985-867-9605

Maine Podiatric Medical Association
Michelle Kurlanski, DPM, President
15 Sewell St., #2
Portland, ME 04102
Phone: 207-846-9190
mkurlanski71@yahoo.com
*James Whipple, DPM, Ex. Dir.
60 Pineland Dr., #210
New Gloucester, ME 04260
Phone & Fax: 207-688-8990
mainefas@yahoo.com

Maryland Podiatric Medical Association - www.marylandpodiatry.org
Stephen Palmer, DPM, President
6100 Day Long Ln., Suite 102
Clarksville, MD 21029
Phone: 443-535-8770
Fax: 443-535-8775
spalmer@columbiafootandankle.com
Richard Bloch, Executive Director
600 Baltimore Ave., Adams Bldg. #301
Towson, MD 21204
410-332-0736/800-560-1818
Richard@SBHPA.com

Massachusetts Podiatric Medical Society - www.massdpms.org
Alfred Phillips, DPM, President
1493 Cambridge St., #781
Cambridge, MA 02139
Phone: 617-665-3570
Fax: 617-665-3598
Gary Adams, Executive Director
10 Maple St., #301
Middleton, MA 01949
Phone: 978-646-9671
gadams@massdpms.org

Michigan Podiatric Medical Society - www.mpma.org
Jodie Sengstock, DPM, President
49450 Hudson Dr.
Canton, MI 48188
Phone: 734-397-1396
Christian Kindsvatter, Ex. Dir.
1000 W. Joseph St., #200
P.O. Box 15339
Lansing, MI 48901
517-484-6762/800-968-6762
chris@kindsvatterassociates.com

Minnesota Podiatric Medical Association
Michelle Barrette, JD, Executive Director
Sievertson & Barrette
1465 Arcade St.
St. Paul, MN 55106
Phone: 651-778-0575
michelle@sivbar.com

31

Mississippi Podiatric Medical Association
B. Tipton Sullivan, DPM, President
1915 Dunbarton Dr.
Jackson, MS 39216
Phone: 601-982-3338
Fax: 601-982-2253
*Amy DeGirolamo, DPM Secretary/Treasurer
1306 Belk Ave.
Oxford, MS 38655
Phone: 662-513-6600

Missouri Podiatric Medical Association
Anthony Lombardo, DPM, President
12255 DePaul Dr., #470
Bridgeton, MO 63044
Phone: 314-739-8863

Steve Carroll, Executive Director
215 E. Capitol
Jefferson City, MO 65102
573-761-5952

Montana Podiatric Medical Association - http://www.mtfootandankle.com
Todd Storm, DPM
931 Highland Ave., #3310
Bozeman, MT 59715
Phone: 406-587-8478
Fax: 406-582-0730
*Marti Wangen, CAE, Exec. Dir.
36 S. Last Chance Gulch, Ste A
Helena, MT 59601
Phone: 406-443-1160
mwangen@rmsmanagement.com

Nebraska Podiatric Medical Association - http://www.nefootandankle.org/
Mark Willats, DPM, President
2 W. 42
nd
St. #2700
Scottsbluff, NE 69361
Phone: 308-532-3600

*Chad Summy, DPM, Treasurer
2705 Samson Way
Bellvue, NE 68123
Phone: 402-331-6387

Nevada Podiatric Medical Association - http://www.nvpma.com/
Jeremy Wood, DPM, President
3777 Pecos-McLeod, #103
Las Vegas, NV 89121
Phone: 702-434-2023
Fax: 702-434-1976
*Michael Kooyman, DPM
2649 W. Horizon Ridge Pk #100
Henderson, NV 89052
Phone: 702-565-6641
mikdpm@hotmail.com

New Hampshire Podiatric Medical Association
Edward Newcott, DPM, President
102 Pleasant St.
Concord, NH 03301
Phone: 603-228-3008
Fax: 603-228-7095
*Stanley Gorgol, DPM, Ex. Dir.
198 Main St.
Salem, NH 03079
Phone: 603-898-5864
feetpower@usa.net

32
New Jersey Podiatric Medical Society www.njpms.org
James Ricketti, DPM, President
2273 Route 33 #204
Hamilton Square, NJ 08690
Phone: 609-587-1674

Herman Hammerschmidt
2 King Arthur Ct., #C
North Brunswick, NJ 08902
732-967-9003/888-FIT-FEET
Hhammerschmidt@njpms.com

New Mexico Podiatric Medical Association www.nmpma.com
Steve Wrege, DPM, President
3908 Juan Tabo Blvd. NE
Albuquerque, NM 87111
Phone: 505-271-9900
Fax: 505-271-0217
*Janet Simon, DPM, Exec Dir.
8300 Carmel Avenue, NE #501
Albuquerque, NM 87122
Phone: 505-797-1001
janetpod@aol.com

New York State Podiatric Medical Association - www.nyspma.org
Robin Ross, DPM, President
PO Box 1023, 2A Hudson Avenue
Shelter Island, NY 11964
Phone: 631-749-2222
Leonard Thaler, Ex. Dir.
1255 5th Ave.
New York, NY 10029
Phone: 212-996-4400
lthaler@nyspma.org

North Carolina Podiatric Medical Association - www.ncfootandankle.org
James Judge, DPM, President
833 Wake Forest Business Park #C
Wake Forest, NC 27587
Phone: 919-570-9061
Fax: 919-570-9064
Eleanor Upton, Ex. Dir.
P.O Drawer 40399
Raleigh, NC 27629
919-872-2224/866-898-2224
contact@ncfootandankle.org

North Dakota Podiatric Medical Association
Timothy Uglem, DPM, President
2400 32
nd
Avenue S
Fargo, ND 58103
Phone: 701-250-8637
Fax: 701-250-1237
*Tracy Alan Hjelmstad, DPM
101 3rd Ave., S.W. - West
Minot, ND 58702
Phone: 701-857-3584
Fax: 701-857-3566

Ohio Podiatric Medical Associatio - www.opma.org
Alan Block, DPM, President
1930 Crown Park Ct #120
Columbus, OH 43235
Phone: 614-293-3668

Jimelle Rumberg, Ex. Dir.
1960 Bethel Rd., Suite 140
Columbus, OH 43220-1815
Oklahoma Podiatric Medical Association - www.okpma.org
M. Derek Smith, DPM, President
1700 N. 5
th
Street
Ponca City, OK 74601
Phone: 918-274-1557

Michael Clark, Executive Director
3233 E. Memorial Rd., #103
Edmond, OK 73013
Phone: 405-286-2800
execdir@okpma.org
33

Oregon Podiatric Medical Association
Thomas Melillo, DPM, President
9900 SW Hall Blvd. #100
Tigard, OR 97223
Phone: 503-245-2420
Fax: 503-245-2445

*Christopher Seuferling, DPM
7940 S.E. Division St., #E
Portland, OR 97206-1046
Phone: 503-775-5846
Fax: 503-775-8054
cseuferling@comcast.net

Pennsylvania Podiatric Medical Association - www.ppma.org
Robert W. Herpen, DPM, President
148 N. 8
th
Street
Philadelphia, PA 19107
Phone: 215-625-5215
rherpen@tuspm.temple.edu
Michael Davis, Executive Director
757 Poplar Church Rd.
Camp Hill, PA 17011
Phone: 717-763-7665
MQD2@aol.com

Puerto Rico Podiatric Medical Association
Sara Lopez Torres, DPM, President
400 Avenue FD Roosevelt #100M
San Juan, PR 00918
Phone: 787-753-2626
*Edgardo Morales, DPM
P.O. Box 2582
Guaynabo, PR 00970
Phone: 787-636-3763

Rhode Island Podiatric Medical Association
Mark Enander, DPM, President
17 Parker St.
Lincoln, RI 02865
Phone: 401-725-8989
*Clyde Fish, DPM
1050 Centerville Rd.
Warwick, RI 02885
Phone: 401-821-6238

South Carolina Podiatric Medical Association www.scpma.org
Trenton Statler, DPM, President
49 Grand Oaks Way
Beaufort, SC 29907
Phone: 843-322-0900
*Sam Christiano, Ex. Dir.
P.O. Box 11096
Columbia, SC 29211
Phone: 803-926-7488

South Dakota Podiatric Medical Association
*Jennifer Ryder,DPM, Sec/Treasurer
2820 Mt. Rushmore
Rapid City, SD 57701
Phone: 605-342-3280
ftdocdr@aol.com
Rylan Johnson, DPM, President
16639 Elk Horn Rd
Piedmont, SD 57769
Phone: 605-718-3300
rylan_j@hotmail.com

Tennessee Podiatric Medical Association
Paul W. Hutchison, DPM, President
7878 Winchester Rd.
Memphis, TN 38125
Phone: 901-365-3668
Fax: 901-362-7099
*Gary Odom, Executive Director
P.O. Box 50437
Nashville, TN 37205
Phone: 615-353-0046
garylodom@aol.com

34

Texas Podiatric Medical Association - www.txpma.org
Samuel Nava, DPM, President
2001 N. MacArthur Blvd. #300
Irving, TX 75061
Phone: 972-254-0680
Fax: 972-254-0683
Don Canada, Executive Director
918 Congress Ave., Suite 200
Austin, TX 78701
Phone: 512-494-1123
don@txpma.org

Utah Podiatric Medical Association - www.utpma.org
Randy Rhodes, DPM, President
333 s. 900 E.
Salt Lake City, UT 84102
Phone: 801-766-0606

Candace Daly
1296 W. 475 S.
Farmington, UT 84025
Phone: 801-599-8519
candacedaly.cjd@gmail.com

Vermont Podiatric Medical Association
*Craig Schein, DPM, President
331 Summer St.
St. Johnsbury, VT 05819
Phone: 802-748-9400
Fax: 802-748-9010
Nicholas Benoit, DPM, Vice President
200 Russ Hill Rd.
South Royalton, VT 05068
Phone: 802-522-4366

Virginia Podiatric Medical Association - www.vpma.org
Annik Adamson, DPM, President
6355 Walker Lane #503
Alexandria, VA 22310
Phone: 703-822-0895

*Jean Kirk
P.O. Box 40399
Raleigh, NC 27629
Phone: 877-406-8762
vpma@uptonassociates.com

Washington State Podiatric Medical Association - www.wspma.org
Richard Frost, DPM, President
400 E. 5th Ave., P.O. Box 3649
Spokane, WA 99220
Phone: 509-838-2531
Fax: 509-459-1595
*Susan Scanlan, DPM, Ex. Dir.
P.O. Box 22368
Seattle, WA 98122
866-343-6999 or 206-922-3587
nwpodiatry@aol.com

West Virginia Podiatric Medical Association
Richard Rauch, DPM, President
123 Health Care Ln.
Martinsburg, WV 25401
Phone: 304-267-5544

*Carrie Ann Lakin, DPM
1313 Quarrier St., #B
Charleston, WV 25301
Phone: 304-347-3668

Wisconsin Society of Podiatric Medicine - http://www.wisconsinpodiatrists.com
Steven Merckx, DPM, President
6 Drumhill Circle
Madison, WI 53717
Steven Frydman, DPM, Ex. Dir.
7929 N. 76th St.
Milwaukee, WI 53223
Phone: 414-371-1000
35
CONGRATULATIONS CLASS OF 2011
A leader in innovative interprofessional medical education
APMSA-horzhalfpgFINAL.indd 1 12/7/10 9:20 AM

Wyoming Podiatric Medical Society
*Timothy Fisher, DPM, President
1303 E. Grand Ave.
Laramie, WY 82070
Phone: 307-721-0022
Fax: 307-721-4866

1/2 page black/white Des Moines University email/ftp

36
36
APMA Affiliated Organizations March 2011
For updated information visit: www.apma.org/affiliated
Specialty Organizations
American College of Foot and Ankle Orthopedics and Medicine- www.acfaom.org
Kirk Geter, DPM, President
2041 Georgia Avenue, NW
Washington, DC 20060
Phone: 202-865-1441

Norman Wallis, PhD, Executive Director
5727 River Rd., Suite 630
Bethesda, MD 20816
Phone: 301-718-6539
Fax: 301-656-0989
nwallis@acfaom.org
American Society of Podiatric Surgeons - www.aspsmembers.org
Kathleen Pyatak-Hugar, DPM, President
142 Chenoweth Lane
Louisville, KY 40207
Phone: 502-897-1616

Tiffany Kildale, Association Manager
9312 Old Georgetown Road
Bethesda, MD 20814
Phone: 301-581-9214
takildale@apma.or
Clinical Interest Organizations

American Academy of Podiatric Sports Medicine www. aapsm.org
Karen Langone, DPM, President
365 County Road, 39A #9
Southampton, NY 11968
Phone: 631-287-1818

Rita Yates, Executive Director
109 Greenwich Dr.
Walkersville, MD 21793
Phone: 301-845-9887 or 888-854-FEET
Fax: 301-845-9888
ritayates2@aol.com
American College of Foot and Ankle Pediatrics
Yaron Raducanu, DPM, President
936A General Booth Blvd.
Virginia Beach, VA 23451
Phone: 757-228-1955
Fax: 757-228-3095
Debi Grinberg, Secretary/Treasurer
2221 Glenrose Ct.
Virginia Beach, VA 23456
Phone/Fax: 757-416-9000
kidsfeet@gmail.com

American Society of Podiatric Dermatology
M. Joel Morse, DPM, President
3301 New Mexico Avenue, NW #228
Washington, DC 20016
Phone: 202-686-0932
foxhallfoot@aol.com

American Society of Podiatric Medicine
Elliott Udell, DPM, President
120 Bethpage Rd.
Hicksville, NY 11801
Phone: 516-935-1113
Fax: 516-349-8153
Warren Simmonds, DPM, Secretary
1111 Kane Concourse, Suite 111
Bay Harbor, FL 33154
Phone: 305-866-9608
Fax: 305-866-1750
37

37

Related Organizations
American Academy of Podiatric Practice Management- www.aappm.com
Jeffrey Frederick, DPM, President
27901 Woodward Avenue, Suite 110
Berkley, MI 48072
Phone: 248-545-0100
Fax: 248-545-1285
Christian Kindsvatter, Executive Director
1000 W. St Joseph Highway #200
Lansing, MI 48915
Phone: 517-484-1930; Fax: 517-485-9408
office@aappm.org

American Association for Women Podiatrists
www.americanwomenpodiatrists.com
Sheryl Strich, DPM, President
6042 Sierra Siena Road
Irvine, CA 92603
Phone: 949-854-3636; Fax: 949-854-3637

American Association of Colleges of Podiatric Medicine---www.aacpm.org
Michael Trepal, DPM, Chairperson
115 Henry Street
Brooklyn, NY 11201

Moraith North, Executive Director
15850 Crabbs Branch Way, Suite 320
Rockville, MD 20855
Phone: 301-948-9760
Fax: 301-948-1928

American Association of Hospital and Healthcare Podiatrists---
www.hospitialpodiatists.org
Lawrence Santi, DPM, President
240 E. 5th St.
Brooklyn, NY 11218
Phone: 718-435-1031
Fax: 718-435-9617
Frank Rinaldi, DPM, Executive Director
8508 18th Ave.
Brooklyn, NY 11214
Phone: 718-259-1822
Fax: 718-259-4002

American Podiatric Medical Students' Association www.apmsa.org
Adam Siegel, President
2936 N. Clark St. #4F
Chicago, IL 60657
Adam.siegel@my.rfums.org
Dorothy Cahill McDonald, Executive Director
9312 Old Georgetown Rd.
Bethesda, MD 20814
Phone: 301-581-9263;apmsadcm@apma.org
American Podiatric Medical Writers Association
Howard Malin, DPM, President
2250 Bear Den Rd., #210
Frederick, MD 21701
Phone: 301-668-1941
Barry Block, DPM, JD, Executive Director
P.O. Box 750129
Forest Hills, NY 11375
Phone: 718-897-9700
38
38

American Society of Podiatric Medical Assistants - www.aspma.org
Anna Fabach, PMAC, President
c/o Dr. Maria Cohen, 414 Oak Park Avenue
Seattle, WA 98122

American Society of Podiatric Executives
Susan Scanlan, DPM, President
P.O. Box 22368
Seattle, WA 98122
Phone: 206-922-3587
Fax: 206-922-3587
nwpodiatry@aol.com

APHA APMA Chapter
p/u from 2010
ad black/white

Joining APHA
T
he American Public Health
Association (APHA) is the
oldest and most diverse
organization of public health
professionals in the world and
has been working to improve
public health since 1872. APHA
and its state afliates represent
more than 50,000 health
professionals and others who
work to promote health, prevent
disease, and ensure conditions
in which we all can be safe
and healthy.
Join The Podiatry
Section Today at
www.apha.org/about/
membership/
Is A Wise Investment In Your Future
And The Future Of Worldwide Health
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in theii futuie enueavois.
40
40
Pre-Practice Year Preparation Checklist
Task Resources Cost Time Frame
Practice options/job
opportunities
APMA News classifieds and
eNews, www.apma.org, YM
lectures and Salary/Benefits
Assessment, AAPPM, PM News
Start ASAP.
Begin applying 12-
18 months before
end of residency
CV YM Exchange Aug/Sept 2005
(available at www.apma.org
under Young Members section)
Complete while in
residency and
update frequently
State Licensing/
PMLexis
www.apma.org/stateboards
under Young Members section
$900 PM Lexis dates and
processing time vary
per state- check ~1
yr in advance (can
take up to 6 months)
ABPS/ABPOPPM See next page and
www.abps.org
www.aspsfellows.org
www.abpoppm.org

ABPS: $800
FF $1400
FF & RF
ABPOPPM:
$200
ABPS: Register:
~March Exam:
~May/June
ABPOPPM: Register:
~April Exam: ~June
Contracts/Business
Plan
Contact a lawyer who specializes
in this area, also AAPPM
various Start early, leave
time to negotiate
Apply for DEA # http://www.deadiversion.usdoj.
gov/onlineforms.htm and/or see
DEA license info in this guide

$551 (for 3
years)
~6 weeks (need
state license)
Insurance plans Company specific- need hospital
privileges first if going solo
Apply as soon as you
have license & know
your practice area
CAQH (Council for
Affordable Quality
Healthcare)
https://www.caqh.org (need a
provider ID from an insurance
co. first)
Helps to eliminate
extra paperwork
with insurance
credentialing
Medicare/Medicaid
Provider #

http://www.cms.hhs.gov
Applications:
http://www.cms.hhs.gov/CMSfo
rms/downloads/cms10115.pdf

Process takes at
least 3 months, can
retro-bill up to 90
days
NPI # (National
Provider Identifier)
https://nppes.cms.hhs.gov/NPP
ES/StaticForward.do?forward=st
atic.instructions
http://www.cms.hhs.gov/cmsfor
ms/downloads/CMS10114.pdf
Must have state
license
Malpractice/
disability Insurance
See advertisers in this guide and
contact state society
varies 30 days prior to
practicing
Hospital Privileges Location specific- need
residency certificate but start
process before completion
varies Process can take
several months
DME Provider #
(Durable Medical
Equipment)
http://www.cms.hhs.gov/cmsfor
ms/downloads/cms855s.pdf

Only one is needed
per office, may need
if going solo
Association
Membership
www.apma.org
www.aspsmembers.org
varies Remember to join or
continue
membership at start
of practice
41

41
Additional Information

To simplify processes and for subsequent applications, keep copies of your state medical
license, state drivers license/state ID, DEA card, proof of malpractice insurance, residency
completion certificate, and letter of hospital staff privileges. In addition, here are other
important pre-practice items for consideration:

License to Practice/PM Lexus Scores
The actual license to practice podiatric medicine is issued by the State Board. Since states
vary in their individual requirements for licensure and practice, it is a good idea to research
their regulations well in advance. It is advisable to send a registered letter to the state
board of licensing of your choice to inform them of your status in training and your
intentions, to request an application, and to become familiar with any additional procedural
requirements. This is typically handled in conjunction with Boards Part III. Contact the
NBPME at www.nbpme.org for more Part III information about testing sites, deadlines and
fees. To request PM Lexus scores, contact the Federation of Podiatric Medical Boards at
www.fpmb.org or call 561-752-3735.

Association Membership
Membership in your national (APMA), state, and local associations provides many resources
of benefit to you as you progress in your career. Complete the enclosed coupon to receive
membership information and to take advantage of complimentary first year resident
membership. APMA and its Young Members program will help you transition from a
resident to a successful practicing podiatric physician.

Each state has their own set of processing procedures for obtaining membership as a
practicing podiatric physician. It is important to know these procedures so you may
expedite your application process. You can view these procedures by visiting
www.apma.org/MembershipProcess.

Supportive Professional Contacts
Three specific contacts that are crucial prior to establishing a practice include an attorney,
an accountant, and a banker. The attorney handles personal as well as business matters.
Early establishment of this relationship is especially beneficial as an attorney can review any
contract proposals and aid in the formation of a contract acceptable to all parties. The
accountants role may be expanded beyond the obvious to include managerial advice and
in-office support. The bankers position is essential in obtaining an initial office loan and
may establish the relationship often necessary for subsequent credit and loans. A word of
caution must be given to those considering the use of close friends or relatives in any of
these positions. What seems advantageous at first can cause hardship later.

Office/Malpractice Insurance
It is recommended that an insurance study be completed prior to joining or opening a
practice. To insure the practitioner and the office of adequate coverage, inclusions not to be
overlooked are adequate health insurance, life insurance, business premises (fire and theft),
personal liability, workers compensation, and personal disability policies. Malpractice
insurance must also be obtained and is often available at reduced rates for the new
practitioner. Check the advertisers listed in this guide and with APMA and your state
component for suggestions on insurers. Be sure to get cost quotes. This process can take
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42
2-6 weeks. You will need insurance before applying for any hospital privileges or other
health insurance companies.

Hospital/Surgical Center Affiliations

In an effort to assist APMA members in resolving difficulties that arise during privileging and
credentialing processes, APMA, has developed a Hospital Privileging and Credentialing
Resource Guide (Guide) to provide APMA members with tools and suggested approaches
that will help them obtain appropriate hospital privileges.

Part One of the Guide provides an overview of podiatric medicine, including the education,
training, and experience of podiatric physicians. This information will assist the podiatric
physician in educating the hospital and the medical staff about the podiatric medical
profession.

Part Two provides an overview of state and federal laws and regulations that govern
hospitals and the privileging process, and will help APMA members to understand their
rights and responsibilities.

Part Three focuses on the organization of hospitals and medical staffs and provides the
podiatric physician seeking privileges a guide on how to effectively navigate internal hospital
procedures. Part Three also provides suggestions on how to become an active member of
the medical staff and how to advance the podiatric medical profession from inside the
hospital.

Part Four offers suggestions on how to advocate beyond the hospital setting, including
when and how to seek legal, regulatory, or legislative remedies.

The Appendix provides issue briefs, model bylaws, and other resources that podiatric
physicians can use in their advocacy efforts.

The Guide is only available on the APMA Members website at www.apma.org/hospitalguide.

While not all practitioners seek privileges at the local hospital facility, staff membership is
beneficial to some. In addition to being a site for surgical procedures, the hospital serves as
a source of physician and staff referrals. You should decide early whether or not to seek
hospital privileges since the application and processing time is very time-consuming. Keep
in mind that most, if not all, surgery centers require hospital privileges for a least one
hospital in order to receive surgery center privileges. This is in the event that a patient is
admitted directly from a surgery center in case of an unforeseen emergent need. Allow 3-
5 months for submission approval. For more information on hospital privileges visit:
http://www.apma.org/HospitalPrivileges.

Durable Medical Equipment Provider Number
You will need a DME number if you plan on dispensing any durable goods from
your office (i.e. pre-fab orthotics, cam boots, ankle braces, crutches, etc). Only one DME
number is allowed per office, so you probably wont need to apply for one unless you are
opening a practice or buying a solo practice. For more information, go to
http://www.cms.hhs.gov/cmsforms/downloads/cms855s.pdf

Health Insurance Credentialing
43

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This is often the last thing that you can do after completing all of the steps above if going
solo many insurance companies will require that you be on staff at a hospital prior to
giving you your provider number and fee schedule. If you hire a billing company, many will
handle the insurance company credentialing and fee schedule negotiations for you (for a
fee). They will also know which insurance companies can be applied to prior to hospital
staffing. This can take up to 1 year in some cases, but typically 3-6 months for processing
on most insurance companies. The CAQH application (described above) can simplify this
process. Be aware that some insurance companies may be closed to new providers; this is
often where a billing company may be able to help you as well or working part-time with an
established group.

Referral List
It is important to establish a list of potential referral contacts prior to entering practice. The
list should include all local physicians as well as any physicians you have met and/or worked
with, shoe stores, pharmacies, and other beneficial businesses. In addition, make contact
or become an active participant in neighboring community service organizations such as the
Lions Club, Kiwanis Club, Shriners, and the local YMCA.

APMA Affiliated and State Component Membership
A complete contact listing of various professional and state organizations is maintained by
the American Podiatric Medical Association at www.apma.org and is also available in this
Guide. The affiliate organizations provide expertise and information about dermatology,
orthopedics, surgery, radiology, podopediatrics, and more.

Advertising
Public relations is crucial to any successful practice. Though this topic is quite broad, a few
essentials must be addressed, such as telephone service and listing, WebMD little blue
book, office signs and printing, business cards, and announcement letters. You might also
want to consider a website if one is not already established. Keep in mind that the fastest
and least expensive approaches are not always the best available options.

ABPOPPM Board Certification

The American Board of Podiatric Orthopedics and Primary Podiatric Medicine (ABPOPPM)
offers a comprehensive board qualification and certification process in podiatric medicine
and orthopedics. Podiatric Medicine and Orthopedics is the medical specialty concerned with
the comprehensive and continuous foot health care of patients. It integrates the biological,
biomechanical, rehabilitative, clinical and behavioral sciences and encompasses first contact
care, continuous care, long term care and general medicine. For more information on
ABPOPPM and Board Qualification and Certification as wells as resources such as case
studies, indexes, worksheets, study guides, visit www.abpoppm.org

ABPS Board Certification
You are now board QUALIFIED, and you are about to begin practice and try to figure out
how to treat patients, bill, and, oh yes, somewhere along the way you have to gather cases
to submit to the American Board of Podiatric Surgery to become board CERTIFIED. Since
you just finished studying for the computer board qualification test the certification test
probably isn't the first thing on your mind the first day of practice. But, with just a small
44
44
about of knowledge you can make your life a lot easier when putting together your cases in
the next 7 years.
Here are the top ten things to remember when starting your surgical practice for your case
log:
1. Log onto ABPS.org and print out and thoroughly review the ABPS 220 document. This is
a document with instructions for preparing the application and case documentation. This
explains everything you need to know. It is important to review this document prior to
sitting down and tackling daunting task of gathering cases.
2. Print out the ABPS 210 document. This is the format for the list of cases that you will
send ABPS. You can make a draft copy in pencil of your best cases for each category.
Patients are divided into categories of surgery and include: Name, age, gender, date of
Surgery, and location of surgery (i.e. hospital name). Keep a detailed log/spreadsheet of all
cases and notes if you believe it is potential board quality. This will make it much easier for
you to sort your cases after a few years have passed since you initially reviewed them.
3. Make sure you have good pre-operative x-rays before surgery and must include: patient
name, right or left marker radiograph date and facility where taken (not too dark or too
light and the pathology must be clearly shown, remember the reviewers can't see the actual
patient clinically so the x-rays and notes must provide an accurate representation.)
4. Take good post-operative x-rays in the OR. X-rays are required within the first 72
hours and chances are you won't be seeing your patient back in the office in this time
frame. Don't forget to take home your copy of the x-ray for your chart because you never
know what can happen to that c-arm picture after surgery and over the next couple of
years. You must also have x-rays at least 4 weeks out and radiographs showing final
healing.
5. Make sure you obtain copies of and review the operative reports and you must be listed
as the surgeon, not assistant or co-surgeon.
6. Obtain and save all copies of your surgical patients MRI/CT scans. You may have to
submit the actual film or digital copies not just the report.
7. Keep thorough detailed office notes on all your surgical patients.
8. Write good hospital progress notes. If your patient stays in the hospital greater than
24 hours you will need to submit all your notes written for that patient.
9. Documentation needed for every case includes:
x Podiatric history and physical Operative report
x Anesthesia Record or Circulators notes
x Pre-op labs
x Progress Notes
x Discharge Summary
x Radiographs/Imaging
45

45
10. Remember you need to show variety in your procedure knowledge and case selection.
For example, 30 first ray procedures are required; some need to be Hallux Valgus surgery,
some Hallux limitus, and some "other" first ray. The exact numbers are listed in the ABPS
220 document.
Stay on top of this information from the start and you will increase your chances of having
your cases accepted and this will ease the stress when it comes to organizing your cases.

NJ Podiatric Medical Assn
Hard copy
Attached
page black and white
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Obtaining A DEA Number

Most new residents need a Drug Enforcement Agency (DEA) number during residency while
others can wait until the final year of residency to apply. For most jobs you will need to
have both a DEA and NPI number to start and/or apply for hospital privileges. Visit the DEA
web site diversion control program section www.deadiversion.usdoj.gov for an online
application. The process takes 6-10 weeks and heres some of the information you will find.

Registration Number
Toll Free: 1-800-882-9539
REGISTRATION SUPPORT

Save time by applying for your DEA Registration on-line. Data will be
entered through a secure connection to the ODWIF on-line web application
system. Minimum requirements: Credit Card and a web browser that
supports 128-bit encryption.

New DEA Number Assignment for Type A (Practitioners) Registrants

To Apply for New Applications for Registration On-Line
To Apply for Registration by Mail
For Registration Changes
(Address, Drug Codes, Name, Schedules)
Duplicate Certificates
Order Forms
For Registration Matters
1-800-882-9539

NEW APPLICATIONS
DEA-224 Retail Pharmacy, Hospital/Clinic, Practitioner, Teaching Institution,
or Mid-Level Practitioner.
MINIMUM ON-LINE REQUIREMENTS
The DEA Forms listed are for those applying to DEA for a controlled substance registration.
Data will be entered through a secure connection to the ODWIF on-line web application
system. Your web browser must support 128-bit encryption.
You will need to have the following information on hand to complete the form:
Tax ID number and/or Social Security Number
State Controlled Substance Registration Information
State Medical License Information
Credit Card (VISA, MasterCard, Discover or American Express)

47
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47
Tamper-Resistant Prescription Pad Features Required

Effective April 2008, all written prescriptions for Medicaid recipients must be on paper with
at least one tamper-resistant feature as outlined by Centers for Medicare and Medicaid
Services (CMS) and defined by a physicians state and must be on paper that meets all
three baseline characteristics of tamper-resistant pads. CMS has outlined these
characteristics as those that:

1. Prevent unauthorized copying of a completed or blank prescription form
2. Prevent the erasure or modification of information written on the prescription by the
prescriber
3. Prevent the use of counterfeit prescription forms.

States are responsible for defining specific features that meet the baseline characteristics in
order for a prescription to be considered tamper-resistant in that state. Therefore, Review
your states web site for guidance on acceptable tamper-resistant features. Additional
information on CMS requirements can be found at:
http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0736.pdf

Please note that prescriptions that are electronic, faxed, or sent via telephone are exempt
from this requirement.

CMS states that failure to comply with this requirement could result in a
withholding of Medicaid reimbursement.

Arizona College of Podiatric Medicine
page black/white/via email

48
48
National Provider Identifier

The Center for Medicare & Medicaid Services (CMS) has announced the availability of a new
health care identifiers for use in the Health Insurance Portability and Accountability Act of
1996 (HIPAA) standard transactions. HIPAA mandated that the Secretary of Health and
Human Services adopt a standard unique health identifier for health care providers.

The NPI must be used by covered entities under HIPAA (generally, health plans, health care
clearinghouses, and health care providers that conduct standard transactions). The NPI
identifies health care providers in the electronic transactions such as claims, eligibility
inquiries and responses, claim status inquiries and responses, referral, and remittance
advices.

The NPI replaces health care provider identifiers used today in standard transactions.
Implementation of the NPI eliminates the need for health care providers to use different
identification numbers to identify them when conducting HIPAA standard transactions with
multiple health plans.

All health plans (including Medicare, Medicaid, and private health plans) and all health care
clearinghouses must accept and use NPIs in standard transactions.

The NPI Application Process

The NPI application is free and you may apply for your NPI in one of three ways:

1. You may apply through an easy-to-use Web based application process. The web
address is https://nppes.cms.hhs.gov
2. You may complete a paper application and send it the Enumerator. A copy of the
application, including the Enumerators mailing address (where you will want to
send it) will be available on https://nppes.cms.hhs.gov or you can call the
Enumerator (Fox Systems, Inc.) to receive a copy. The phone number is 1-800-
465-3203.
3. With your permission, an organization may submit your application in an electronic
file. This could mean that a professional association, or perhaps a health care
provider who is your employer, could submit an electronic file containing your
information and the information of other health care providers.

When gathering information for your application, be sure that all of your information, such
as your social security number and the Federal Employer Identification Number, are correct.
Once you receive your NPI, safeguard its use.

APMA has collected important information for its members. Below are answers to commonly
asked questions as well as useful tips to ease the continuing transition to the NPI.

Frequently Asked Questions

QUESTION: What is the format of the NPI?
ANSWER: NPI is all numeric and is 10 positions in length: the first 9 positions are the
identifier and the last position is a check digit. The check digit helps detect invalid NPIs.
There is no embedded intelligence in the NPI with respect to the health care provider that it
identifies.
49

49

QUESTION: What is the purpose of the NPI? Who must use it and when?
ANSWER: The purpose of the NPI is to uniquely identify a health care provider in standard
transactions, such as health care claims. NPIs may also be used to identify health care
providers on prescriptions, in internal files to link proprietary provider identification numbers
and other information, in coordination of benefits between health plans, in patient medical
record systems, in program integrity files, and in other ways. HIPAA requires that covered
entities (i.e., health plans, health care clearinghouses, and those health care providers who
transmit any health information in electronic form in connection with a transaction for which
the Secretary of Health and Human Services has adopted a standard) use NPIs in standard
transactions by the compliance dates. The compliance date was May 2008 and the NPI will
now be the only health care provider identifier that can be used for identification purposes
in standard transactions by covered entities.

QUESTION: What is a Medicare legacy number?
ANSWER: Legacy provider identifiers include: Online Survey Certification and Reporting
(OSCAR) system numbers; National Supplier Clearinghouse (NSC) numbers; Provider
Identification Numbers (PINs); and Unique Physician Identification Numbers (UPINs) used
by Medicare. Legacy provider identifiers do not include: Employer Identification Numbers
(EINs); or Social Security Numbers (SSNs).

QUESTION: Will a health care provider continue to use other numbers besides the NPI to
identify itself in standard transactions?
ANSWER: Only the NPI may be used for identification purposes for a health care provider in
standard transactions; legacy identifiers (such as the UPIN, Medicaid Provider Number,
Medicare Provider Number, and others) may not be used. Where a health care provider
must be identified in standard transactions for tax purposes, it would use its Taxpayer
Identifying Number as required by the implementation specifications. Health care provider
identification numbers other than the NPI may continue to be used in the internal processes
and files of health plans or health care clearinghouses if they wish to continue to use those
identification numbers in those internal processes and files.

QUESTION: Will a health care providers NPI ever change?
ANSWER: The NPI is meant to be a lasting identifier, and would not change based on
changes in a health care providers name, address, ownership, membership in health plans,
or Healthcare Provider Taxonomy classification. There may be situations where use of an
NPI for fraudulent purposes results in a health care provider requesting a different NPI;
such situations will be investigated and a different NPI may be assigned to the requesting
health care provider.

QUESTION: Should I keep a copy of the NPI notification that I received from the National
Plan and Provider Enumeration System (NPPES)?
ANSWER: Yes. You will need the NPI notification when you enroll or make a change to your
Medicare enrollment information. Be aware that applying for an NPI does not replace any
enrollment or credentialing processes with any health plans, including Medicare.

Search and Review NPIs for Free

Looking up National Provider Identifiers (NPIs) of other providers is a free service from the
federal government. The Centers for Medicare & Medicaid Services (CMS) offers two
50
50
different ways to access the information: an online NPI Registry and a downloadable data
file.

Both methods reveal provider information from the National Plan & Provider Enumeration
System (NPPES) database, and neither requires a password or payment. The data were
collected when providers applied for NPIs.

For more information on NPIs, visit
http://www.cms.hhs.gov/NationalProvIdentStand. Providers can apply for an NPI online at
https://nppes.cms.hhs.gov or can call the NPI enumerator to request a paper application at
1-800-465-3203.

Two new educational products have been posted to the CMS Web site:

x For Providers who are Organizations
http://www.cms.hhs.gov/NationalProvIdentStand/Downloads/NPI_FactShe
et_Org_Provi_web_07-03-07.pdf

x For Providers who are Sole Proprietors
http://www.cms.hhs.gov/NationalProvIdentStand/Downloads/NPI_FactShe
et_Sole_Prop_web.pdf

CMS has posted several documents to help providers understand what the downloadable file
will look like, including a Read Me file, Header File, and Code Value document for the
downloadable file on the CMS NPI Web site at
http://www.cms.hhs.gov/NationalProvIdentStand/06a_DataDissemination.asp.

Podiatric physicians may wish to review their own information which can also be found in
the database. Podiatrists can correct your own information, if necessary, by obtaining and
submitting an NPI application/update form (CMS-10114). Providers who need assistance
can contact the NPI Enumerator at customerservice@npienumerator.com or (800) 465-
3203.

The NPI Registry enables users to search by NPI or by the name of the provider. See
https://nppes.cms.hhs.gov/NPPES/NPIRegistryHome.do for the service.

The downloadable data file includes a very large amount of data (300-800MB) that can be
viewed by a variety of software programs but may require some technical skills to
navigate. See http://nppesdata.cms.hhs.gov/cms_NPI_files.html for the latest update.

http://www.cms.hhs.gov/NationalProvIdentStand/06a_DataDissemination.asp#TopOfPage
This site has more information about the NPPES and NPI data dissemination policies and
procedures.

In Other NPI News

Effective March 2008, the Centers for Medicare & Medicaid Services (CMS) began rejecting
Part B and durable medical equipment (DME) claims that do not have a National Provider
Identifier (NPI) in the primary provider field. For professional claims, the primary provider
fields are the Billing, Pay-to, and Rendering provider fields. If the pay-to provider is
the same as the billing provider, the pay-to provider does not need to be identified.

51

51
Claims can include so-called legacy provider numbers in other non-primary fields, but
those claims will continue to be rejected if the NPI and legacy numbers do not match in the
Medicare NPI crosswalk. If your claims with an NPI are not being paid, you may need to
correct information in the NPI records or Medicare enrollment records to facilitate the
crosswalk.

If your claims with an NPI and legacy number are paid, then it is recommended you submit
a small batch of claims with only the NPI. If those test claims are not paid, contact the
Medicare carrier. Medicare claims must only use an NPI.

Match Type 2 NPIs to IRS Data or Risk Rejection
In an effort to ensure that the data submitted to the National Plan and Provider
Enumeration System (NPPES) for organization healthcare providers (type 2 National
Provider Identifiers) is accurate, the CMS initiated an NPPES-IRS data match to ensure the
legal business name (LBN) and employer identification number (EIN) in NPPES are
consistent with IRS data.

CMS has notified organization healthcare providers that have an EIN/LBN combination in
NPPES that are different from the information maintained by the IRS requesting providers
review and update their LBN and EIN in NPPES. If organization providers can not furnish
data that are consistent with the IRS, CMS will deactivate the NPI in NPPES. CMS will
continue to match these provider data in NPPES against IRS data to ensure the accuracy of
NPPES data. Medicare is rejecting claims that include legacy identifiers in any primary or
secondary provider fields.

Additional Information

Visit http://www.cms.hhs.gov/hipaa/hipaa2 on the web

Visit https://nppes.cms.hhs.gov or call the Enumerator at 1-800-465-3203

For HIPAA information, you may call the HIPAA Hotline: 866-282-0659 or write to:
AskHIPAA@cms.hhs.gov on the web

53

American Board of Podiatric Surgery
Full Page Color
P/u 2008

American College of
Foot and Ankle Surgeons
Proven leaders. Lifelong learners. Changing lives.
Congratulations
Graduates!
Who joins ACFAS? Only the best.
AS A NE W DP M I N YOUR RE S I DE NCY, NOW I S THE TI ME TO S TART
YOUR E VOL UTI ON TOWARD ACHI E VI NG B OARD CE RTI F I CATI ON AS
A F OOT AND ANKL E S URGE ON. AND NO ORGANI ZATI ON CAN HE L P
ME NTOR YOU MORE I N THE NE XT F E W YE ARS THAN ACFAS .

Please accept a complimentary rst-year resident membership in
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and ankle surgeons and the wisdom theyve acquired over the years in ACFAS.
As a resident member of ACFAS, you have access to better resources and better
means of preparing yourself to pass ABPS board exams than those provided by
any other organization. And youll have access to the Colleges
Journal of Foot & Ankle Surgery, advanced CME training,
special residents-only credit union services, and all regular
member benets.
But beyond the practical tools and resources is the imprimatur
of the ACFAS brand, the prestige, and the in-demand status
that is associated with it.
Join your new community of proven leaders: ACFAS.
Joining is easy just go to www.acfas.org/residents to apply, or contact the
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Again, Congratulations ACFAS looks forward to helping you on your way
to a successful career as a foot and ankle surgeon!
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55
State Licensing Terms, Resources, Scope of Practice

1. NATIONAL BOARDS: National Podiatric Medical Board Examinations (NBPME).
Passing Scores; passing requires a grade of at least 75; the numerical grades
received on failed subjects are indicated on the score report. Call 814-357-0487 or
visit www.nbpme.org for more information on fees, deadlines, scores, testing sites
and dates, Part III exam, etc.

2. STATE EXAM/PM LEXUS: States may require written, oral or practical
examinations. "None" means the state has no exam; PM Lexis administered by the
National Board of Podiatric Medical Examiners/Federation of Podiatric Medical
Boards); means that the state uses the clinical competency exam. Contact the
FPMB at www.fbmb.org or 561-752-3735 to request a form to the release PM Lexus
scores.

3. POST-GRADUATE TRAINING: If a state requires a podiatric residency or
preceptorship, the required length of the program is indicated; if the state has
indicated that legislation is pending regarding this requirement, it is noted. "None"
means no post-graduate training is required in that state.

4. APPL.DEADL/EXAM DATE: Application Deadline/Examination Date. Some states
accept applications continually throughout the year; others have definite deadline
dates by which ALL application material must be received.

5. FEES: The initial application/examination/license costs are indicated, as well as
renewal fees, if provided.

6. DURATION OF LICENSE: "1 year" means that the license must be renewed
annually; or as otherwise stated.

7. STATE LICENSE: Contact the state licensing board to apply for a state license.
This is typically done in conjunction with Part III of the Boards.

8. DOCUMENTATION NEEDED:

Undergraduate Transcripts: Official transcripts sent from the undergraduate and
graduate institutions attended prior to podiatric medical school.

Podiatric College Certification: Podiatry college certification of attendance/
graduation/miscellaneous information which is either on the application or on a
separate form.

Photograph(s): One or more photographs must accompany the application; often
the photo must be certified by the Office of Student Records or notarized by a Notary
Public as to its authenticity.

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Podiatry Diploma: Most states require only a copy of the D.P.M. diploma to be
sent to the licensing board; some states require the applicant to bring the original
diploma with him/her during the oral interview/examination.

Pod. Col. Transcripts: Official transcripts from the podiatric medical school
(usually with the D.P.M. degree indicated). Again, transcripts with the degree
indicated cannot be issued before graduation; letters, however, can be sent
indicating the person is scheduled to graduate.

Character References: Reference letters or forms attesting to good moral/ethical/
professional character usually completed by a licensed podiatrist or other physician.

OTHER IMPORTANT RESOURCES: APMA STATE REFERENCE MANUAL

The APMA State Reference Manual is a selective compilation of the state laws that
regulate the nation's health care system including scope of practice and
nondiscrimination sections as a resource to assist members in understanding state
laws since the number and complexity of state laws governing the managed care
industry and the practice of medicine is so overwhelming.

The manual provides the exact statutory text and corresponding legal citations for
state scope of practice and nondiscrimination laws, along with any relevant
amendments, noteworthy court cases, and opinions of attorneys general.

Created by the APMA for its members, this manual to be used as a general resource
for members about state statutes pertinent to the practice of podiatric medicine and
surgery. However, APMA is not offering legal or other professional advice, and the
material is not a substitute for the services of an attorney in a particular jurisdiction.
APMA encourages users of the State Reference Manual who need legal advice on
issues that evoke state statutes to consult with a competent attorney. Additionally,
since state law is subject to change, guide users should refer to state governments
and case law for current or additional applicable material.

APMAs State Reference Manual features include:

Prompt Payment Provisions is a compilation of state laws requiring healthcare
insurers to make timely payments for insurance claims, and it can be viewed at
http://www.apma.org/PromptPaymentProvisions, or on a state-by-state basis at
http://www.apma.org/StatutesbyState.

Ankle and Amputation Provisions and the Scope of Practice Statutes and
Regulations Comparative Study are available at
http://www.apma.org/ScopeofPracticeProvisions.

State Ankle Provisions is a map of the 43 states in this Guide that include the ankle
in the scope of practice for podiatric physician and is also available on the scope of
practice Web site.

Hospital Privileges and Medical Staff Provisions was recently added to the APMA
State Reference Manual. The provisions refer to the category of state laws and
regulations that governs the medical staff and the hospital privileging process.
Although the majority of hospitals in the US credential podiatric physicians, some
57

57
hospitals either provide limited privileges that do not meet the education, training,
and experience of the DPM applicants or mandate conditions, such as co-
admittance or restrictions on H&P. The APMA surveyed the laws and regulations of
50 states and the District of Columbia and found that 35 states and the District of
Columbia have statutory or regulatory provisions governing the treatment of non-
MD/DO in the hospital privileging process. For more information on hospital
privileges visit: http://www.apma.org/HospitalPrivileges.

APMA also has added profiles of state legislatures and links to state governments,
legislatures, and licensing agencies to the web pages dedicated to state statutes:
http://www.apma.org/StatutesbyState.

Now available are two recently updated comprehensive charts on Scope of Practice
and Podiatric Medical Licensure laws and regulations. The scope of practice chart
provides APMA members with statutes and regulations on the definition of DPM,
scope of practice, supervision authority over physician extenders, and prescription
authority. This compilation provides the scope of practice provisions for podiatric
physicians in all 50 states, the District of Columbia, and Puerto Rico. The content is
based on the language found in the practice act for podiatric physicians in each
state.

Histology Associates
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76
Temporary License Information
State Is a training, temporary
or limited license
required by your state
for residency training?
Type of license required
Alaska* yes temp
Arkansas* yes temp
California yes residency (training-limited)
Colorado yes training
Connecticut yes interim permit
Delaware yes podiatry in training
District of Columbia no full
Florida yes temp
Idaho* no full
Iowa yes temp
Louisiana yes podiatry in training
Maryland yes registered
Michigan yes residency limited training
Minnesota yes podiatry in residency
Mississippi* yes limited
Missouri yes limited
Montana* yes limited
Nevada* yes permit
New Hampshire* yes permit
New Mexico yes training
New York no full
North Carolina* yes limited
Ohio yes limited/temp
Oklahoma yes temp
Pennsylvania yes academic
Tennessee yes temp
Virginia yes residency license
West Virginia* yes provisional
Wisconsin yes limited
Wyoming* yes temporary or full
* These states have no podiatric training
Source: AACPM Office of Graduate Services, July 2010
Temporary License Information
or limited license
Type of license required
Alaska* yes temp
Arkansas* yes temp
California yes residency (training-limited)
Colorado yes training
Connecticut yes interim permit
Delaware yes podiatry in training
District of Columbia no full
Florida yes temp
Idaho* no full
Iowa yes temp
Louisiana yes podiatry in training
Maryland yes registered
Michigan yes residency limited training
Minnesota yes podiatry in residency
Mississippi* yes limited
Missouri yes limited
Montana* yes limited
Nevada* yes permit
New Hampshire* yes permit
New Mexico yes training
New York no full
North Carolina* yes limited
Ohio yes limited/temp
Oklahoma yes temp
Pennsylvania yes academic
Tennessee yes temp
Virginia yes residency license
West Virginia* yes provisional
Wisconsin yes limited
Wyoming* yes temporary or full
* These states have no podiatric training
77
State Is a training,
temporary or limited
license required by
your state for
residency training?
If yes,
type (full,
other)
Is passage of
Part I of the
ABPME exam
required for a
training license?
Is passage of Part
II of the ABPME
exam required for a
training license?
California yes yes yes
Colorado yes yes yes
Connecticut yes yes yes
Delaware yes yes yes
District of Columbia no full yes yes
Florida yes yes yes
Iowa yes yes yes
Louisiana yes yes yes
Michigan yes yes yes
Minnesota yes yes yes
Missouri yes no response no response
New York no full yes yes
Pennsylvania yes yes yes
Tennessee yes yes yes
Virginia yes yes yes
Sources: Direct calls to State Podiatric Licensing Boards
State Podiatric Licensing Board Websites
States Not Offering Podiatric Residency Training have not been included
Passage of NBPME for Residency Training Licensure
State Is a training,
temporary or limited
license required by
your state for
residency training?
If yes,
type (full,
other)
Is passage of
Part I of the
ABPME exam
required for a
training license?
Is passage of Part
II of the ABPME
exam required for a
training license?
California yes yes yes
Colorado yes yes yes
Connecticut yes yes yes
Delaware yes yes yes
District of Columbia no full yes yes
Florida yes yes yes
Iowa yes yes yes
Louisiana yes yes yes
Michigan yes yes yes
Minnesota yes yes yes
Missouri yes no response no response
New York no full yes yes
Pennsylvania yes yes yes
Tennessee yes yes yes
Virginia yes yes yes
Sources: Direct calls to State Podiatric Licensing Boards
State Podiatric Licensing Board Websites
States Not Offering Podiatric Residency Training have not been included
Passage of NBPME for Residency Training Licensure
78
or limited license
If YES, type Is passage of Part I
of the NBPME exam
required for a
training license?
Is passage of Part II
of the NBPME exam
required for a
training license?
Alabama no
Arizona no
Georgia no
Illinois no
Indiana no
Kentucky no
Maryland yes no no
Massachusetts no
New Jersey no
New Mexico yes training no no
North Carolina yes limited no no
Ohio yes limited/temp no no
Oklahoma yes temp no no
Oregon no
Rhode Island no
Texas no
Utah no
Vermont no
Washington no
Wisconsin yes limited no no
Sources: Website/Direct Calls to State Podiatric Licensing Boards
Note: Some individual institutions may require passage even if the state does not.
States Without Podiatric Residencies (Not Included Above)
*Alabama Alaska
Arkansas Hawaii
Idaho Kansas
Maine *Maryland
Mississippi Montana
Nebraska Nevada
New Hampshire *New Mexico
*North Carolina North Dakota
Puerto Rico South Carolina
South Dakota *Tennessee
*Vermont West Virginia
Wyoming * Military or VA Training Only
States Not Requiring Passage of NBPME Parts I and II for Residency Training
ASICS
IS A PROUD CORPORATE
MEMBER OF THE APMA
running releases more than just sweat.
the gel-kayano
17. biomechanically engineered for your foot.

Congratulations Class of 2011
Best wishes for your future career
from the entire TUSPM community!

II.
Debt Management
Congratulations and best of
luck to the class of 2011!
Harold Glickman, DPM
Washington, DC
Congratulations and
welcome to the profession.
Be involved, be active, and
give back!
Matthew Garoufalis, DPM
Chicago, IL
83

Navigating the Repayment Process

Understanding your loan portfolio is the first step towards effectively managing its
repayment. Each of your loans will have its own set of repayment terms and conditions to
consider.

We have designed the following information to provide you with the basics of student loan
repayment. Once you have reviewed the information, you will have the knowledge needed
to develop and implement your own personal repayment strategy. Having a strategy is the
key to your success.

Consider the following questions about your loan portfolio as you read through the
information:

What are your payments, and when are the payments due?

Can you afford these payments?

Do you have loans with different interest rates?

What is your lender/servicers capitalization policy?

Are your current loans eligible for borrower benefits?

Do you have federal educational loans? Private education loans? Other debt?

Do you know who your lender/servicer(s) are?

Who did you borrow from? Who do you pay back?

Have you updated your school, lender/servicer with any address or name changes?

One of the most common reasons borrowers default on student loans is failing to
update their address with their lender/servicer(s).

Managing your student loans and other personal finances effectively will influence how
quickly you achieve your financial and professional goals in the future. Your
lenders/servicers, professional associations and financial aid office can be essential
resources as you begin to navigate the repayment process.

84
84

Your Rights and Responsibilities

As a borrower, you are required to:

x Repay your student loan according to the agreed repayment schedule

x Notify your loan servicer of anything that affects your ability to repay or which may
impact your eligibility for deferment or cancellation of the loan

As a borrower, you have a right to:

x Written information on loan obligations, including consolidation

x An explanation of default and its consequences

x A copy of your promissory note and return of the original note when the loan is paid in full

x Prior to repayment, request balance information and repayment schedule

x Be notified if your loan is sold, with information on the new holder

x A federal subsidy, if eligible

x A grace period, if applicable

x Prepay your loan early without penalty

x A deferment, if eligible

x Request forbearance
Federal Student Aid Ombudsman

An ombudsman resolves disputes from a neutral, independent viewpoint and will informally
conduct impartial fact-finding about your complaints.

U.S. Department of Education
FSA Ombudsman
830 First Street, NE, 4
th
Fl.
Washington, DC 20202-5144
877-557-2575; www.ombudsman.ed.gov
Tracking Your Loans

National Student Loan Data System (NSLDS)
Phone: 800-4-FED-AID
www.nslds.ed.gov

NSLDS is the U.S. Department of Educations central database for student aid. It receives
data from schools, guarantee agencies, and other Department of Education programs.
NSLDS provides a centralized, integrated view of Title IV loans that are tracked through
85

85
their entire cycle; from aid approval through closure. Use this website to make inquiries
about your Title IV loans. The site displays information on loan amounts, outstanding
balances, loan statuses, disbursement, and lender/servicer contact information.

Paying Your Debt Wisely

Debt does not usually happen overnight. It takes time often building gradually over a period
of time. And that is the best way to get out of debt slowly, over a period of time.

~ Prioritize Your Debt ~

List all your debts; then rank them according to the rate of interest (if you are unsure of the
rate, check your loan statement or contact your lender). Concentrate on paying off the
higher interest debt first while continuing to pay the minimum amount due on all other
debt. Once the highest rate debt is paid off, add the total you were paying on this debt to
the next one on your list. This way, you will have more to pay off each debt on your list,
with the benefit that these payments are already built into your budget. Be sure to continue
paying the minimum amount due on your remaining debts so that it does not affect your
credit.

The recommended pay-off method for debt:

1. Credit Cards
2. Residency/Relocation and/or Private
3. Grad PLUS
4. Unsubsidized Stafford
5. Subsidized Stafford
6. Perkins, HPSL, Institutional
7. Consolidation (depending on the interest rate)

Grace Period

Many student loans provide a grace period immediately following graduation. This is a
time when payments are not required, and on subsidized loans, interest does not accrue.
The grace period must be used before you can obtain deferments. Below is a listing of grace
periods for various loan programs.

Loan Program Grace Period
Perkins 9 months
HPSL 12 months
Institutional 12 months
Stafford 6 months
Grad PLUS
(disbursed after July 1,
2008)
6 months
Federal Consolidation No Grace
Residency/Relocation Check with Lender
Private Check with Lender

86

Loan Programs

If you took a leave of absence from your education, your loans were placed in grace at that
time. Whether or not you receive another grace period upon graduation depends on the
length of time you are away from school and the policies of the individual loan program. The
status of your grace period is vitally important since it usually affects when your deferment
period begins (if applicable) and ultimately, when actual loan repayment begins.

Stafford Loan (Federal)
6 month grace period
Loans disbursed after July 1, 2006 have a fixed interest rate at 6.8%
Loans disbursed prior to July 1, 2006 have variable interest rate, capped at
8.25%
Subsidized Stafford is interest free during school and grace periods
Unsubsidized Stafford accrues interest during school and grace periods
Mandatory forbearance for internship/residency available
Various repayment options available
Consolidation available
Borrower benefits may be available (check with lender)
No penalty for pre-payment

Grad PLUS Loan (Federal)
Loans disbursed after July 1, 2008 have a 6 month grace period
Loans disbursed prior to July 1, 2008 have no grace period and must enter
repayment immediately after graduation (or apply for deferment or forbearance)
Interest rate fixed at 8.5%
Consolidation available
Borrower benefits may be available (check with lender)

Consolidation Loan (Federal)
No grace period
Interest rate fixed based on weighted average of loans at time of consolidation
rounded up to nearest 1/8 of 1% (capped at 8.25%)
Consolidated subsidized Stafford is interest free during school. Consolidated
unsubsidized Stafford, Perkins, and HPSL loans accrue interest during school
87

87
Perkins and Health Profession Student Loan (Federal)
x Perkins 9 month grace period
x HPSL 12 month grace period
x Interest rate fixed at 5%
x Subsidized during in-school and grace periods
x HPSL has unlimited residency deferment (if qualified)
x Consolidation option available
x Perkins has mandatory forbearance for internship/residency
x Perkins has loan forgiveness (if qualified)
x No penalty for pre-payment

The two primary factors that contribute to the overall cost of your loans are:

1) Interest is what the lender charges you to use their money. Different loans carry
different interest rates. Interest on all federal loans borrowed is calculated on a simple
daily basis. The following formula demonstrates how the simple interest is calculated
between payments:
Average daily balance between payments
x Interest rate
x Number of days between payment (365.25)

The loan holder first applies your payment to late charges or collection costs on your
account (if any), and then to the interest that has accumulated (accrued interest). The
remainder of the payment is then applied to the principal balance. Just as the accrued
interest varies monthly (depending on how many days elapse between the receipts of
payment), the amount of a payment applied to accrued interest and the amount applied
to principal also will vary monthly. A breakdown of how your payments are applied
should be on your billing statement. If not, ask your loan holder/servicer.

2) Capitalization occurs when a lender adds any accrued and unpaid interest to the
principal balance of your loan (The principal of your loan is the amount you originally
borrowed). Therefore, the balance of your loan increases and, in turn, it causes the
principal to grow significantly. The effect of capitalization is that your interest begins to
accrue interest. This can be a costly process for you, so you will want capitalization to
occur as infrequently as possible. Several tips to reduce the cost of capitalization include:

x Contact your lender to determine their capitalization policy. This allows you to
understand when your loans are scheduled to capitalize.

x Pay off accruing interest prior to capitalization. This may mean making partial or
full interest-only payments each month while you are in residency.

x File deferment forms on time. Late forms may result in capitalization earlier than
you expected.
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___________________________________________Loan Programs________

Note that some interest rates are fixed and other change monthly, quarterly or annually.
Interest rates can vary depending upon if you are in repayment or deferment status.
Financial quarters are the first day of January, April, July, and October; federal annual
interest rate changes are set July 1. Go to www.bankrate.com for current financial index
rates.
Loan Program
Fixed or
variable?
Interest formula
while in
deferment
Interest formula while in
repayment
Subsidized
Stafford
Disbursed prior
to July 1, 2006
Variable
annually
Subsidized (0%) 91-day Treasury Bill + 2.3%
Subsidized
Stafford
Disbursed after
July 1, 2006
Fixed Subsidized (0%) 6.8%
Unsubsidized
Stafford
Disbursed prior
to July 1, 2006
Variable
annually
91-day Treasury Bill
+ 1.7%
91-day Treasury Bill + 2.3%
Unsubsidized
Stafford
Disbursed after
July 1, 2006
Fixed 6.8% 6.8%
Grad PLUS Fixed 8.5% 8.5%
Private
Variable
monthly
Check with lender Check with lender
Perkins Fixed Subsidized (0%) 5%
Federal
Consolidation
Loan
Fixed
Based on weighted average of loans being consolidated,
rounded to the nearest 1/8
th
of one percent. Only the
Subsidized Stafford portion of consolidated loan is
subsidized (0%) while in deferment.
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Deferment Eligibility Chart

Type Max Time Stafford Loans PLUS Loans Consolidation Loans
Perkins
Loans

Old
Borrower
1
7/1/87 to
6/30/93
New
Borrower
2
7/1/93
New
Borrower 2
7/1/93
Borrower
Consolidates
Before
7/1/93
New
Borrower
2
7/1/93
New
Borrower 2
Full-Time Student None 9 9 9 9 9 9
Half-Time Student None 9 9 9 9 9 9
Graduate Fellowship None 9 9 9 9 9 9
Rehabilitation
Training
None 9 9 9 9 9 9
Military or Public
Health Services (1)
3 Years 9
Military (loans
disbursed 7/1/2001 or
later)
3 Years 9 9 9 9
Natl Oceanic and
Atmospheric Admin.
Corp. (1)
3 Years 9
Peace Corps, Domestic
and Tax-Exempt Org.
Volunteer
3 Years 9
Teacher Shortage 3 Years 9
Internship/Residency
Training
2 Years 9 9
Temporary Total
Disability (2)
3 Years 9 9
Unemployment 2 Years 9 9
Unemployment 3 Years 9 9 9 9
Parental Leave (3) 6 Months 9
Mother Entering/Re-
entering Workforce
1 Year 9
Economic Hardship** 3 Years 9 9 9 9
Military Service (4) None 9 9 9 9 9 9
Military Active Duty
Student (5)
None 9 9 9 9 9 9

This chart is to be used only as a guide. Please contact your loan servicer(s) to
determine eligibility

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A - Old Borrower: Individuals who borrowed their first FFEL loan before July 1, 1993 and
had an outstanding balance prior to taking out a new Stafford loan after that date.

B - New Borrower: A borrower who received an FFEL loan with a first disbursement on or
after July 1, 1993. The borrower has no outstanding principal or interest balance on a
FFEL loan as of July 1, 1993, or on the date the borrower obtains a loan on or after July 1,
1993. This includes a borrower who obtains a Federal Consolidation loan on or after July
1, 1993, if the borrower has no other outstanding FFEL loan when the Federal
Consolidation loan was made.

(1) - Borrowers are eligible for a combined maximum of 3 years of deferment for service in
NOAA, PHS, and Armed Forces.

(2) A deferment may be granted during periods when the borrower is temporarily totally
disabled or during which the borrower is unable to secure employment because the
borrower is caring for a dependent (including the borrowers spouse) that is temporarily
totally disabled.

(3) A parental leave deferment may be granted to a borrower in periods of no more than 6
months each time the borrower qualifies.

(4) A deferment may be granted to a borrower who is serving on active duty during a war or
other military operation or national emergency (including qualifying National Guard duty).

(5) A deferment may be granted to a borrower called to active National or State duty who is
a member of the National Guard or Reserves (including retired members) and who was
enrolled at least half time at an eligible school at the time of, or within 6 months prior to,
being activated.

Mandatory Forbearance (Residency)

Podiatric residents are eligible for Mandatory Forbearance during their residency years.
Mandatory Forbearance requires that your lender allow you to postpone payment of your
loans during your additional years of training. While this alleviates your monthly payment
obligation, interest is still accruing on the entire balance of your student loans and will be
capitalized upon entering repayment. Federal law mandates that though you are required to
request mandatory forbearance, lenders must grant it on loans for the entire duration of
your residency. This mandatory forbearance is a viable option to postpone making
payments during residency.

We encourage you to keep accurate records concerning your student loans as this will help
you to be aware of forbearance end dates so that you can (re)apply for them in a timely
manner. This will assist you in avoiding unnecessary interest capitalization, delinquency and
default due to missed payments on your student loan obligations. Mandatory
Forbearance requires the following:

x Annual Application

x Continuous Periods to Avoid Capitalization

x Interest Accrues on Subsidized and Unsubsidized

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Repayment Strategies

It is important to note that forbearance provisions might differ on some loans, such as the
Federal Perkins (which requires you to pay at least some interest during forbearance). Be
sure to find out what your loans provisions are, and remember that interest is accruing on
all of the loans during periods of forbearance.
No Prepayment Penalty

All Federal education loans allow prepayment without penalty. For loans that are not in
default, any excess payment is applied first to interest and then to principal. However, if the
additional payment is greater than one monthly installment, you must include a note with
the payment telling the processor whether you want your prepayment to be treated as a
reduction in the principal. Otherwise, the lender will treat it as though you paid your next
payment(s) early, and will delay your next payment due date as appropriate. It is best to
tell them to treat it as a reduction to principal, since this will reduce the amount of interest
you will pay over the life of the loan. Check with your servicer for private and institutional
loans prepayment policies.
Repayment Options

There are five basic options available to you throughout the repayment of your federal
student loans. These plans were designed to make your payments more manageable by
providing you with financial flexibility. Whether your debt is large or small, the repayment
plan you select will impact the overall cost of those loans.

1) Standard Repayment - When you choose this repayment plan, your payment amounts
will be equal throughout the term of the loan. In comparison to the other options, the
Standard repayment plan provides higher payments, but this means lower interest costs.
Standard is the option that allows borrowers to pay education debt in the most proactive
manner. If you do not notify your servicer otherwise, the Standard Repayment plan is the
default plan for loan repayment.

Best Option For: Borrowers whose primary goal is to minimize the total interest cost of
student loan debt.

2) Graduated Repayment - The Graduated Repayment plan allows you to begin with
smaller monthly payments that will gradually increase over time so your loan is repaid by
the end of the repayment term. Though graduated repayment offers lower initial monthly
payments than standard repayment, it may lead to higher interest costs over the life of the
loan because the principal of the loan is not paid off as quickly.

Best Option For: Borrowers seeking temporary relief from their higher loan payments and
expecting an increase in their income in the next few years.

3) Income-Sensitive / Income-Contingent Repayment - When a borrower selects
Income-Sensitive (FFELP option) or Income-Contingent (Direct Loan option) as a repayment
plan, the borrower must provide documentation of their expected income the monthly
payment amount will be based on a percentage of the expected total gross monthly income
received from all sources. This plan must be reapplied for each year and income
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documentation will be required. If this plan does not meet a borrowers needs, the Income-
Based Repayment may offer additional flexibility with lower payment amounts.

Best Option For: Borrowers that have a lower income, or are experiencing a financial
hardship, and need assistance making their monthly payment.

4) Income-Based Repayment - Income-based repayment basically means that the
amount of your monthly payment is calculated based on your current income and is
evaluated each year. The Income Based Repayment (IBR) Plan takes effect on July 1, 2009
and applies to Federal Stafford, Graduate PLUS, or Consolidation Loans made under the
FFEL or Direct Loan Programs.

Best Option For: Borrowers who are looking for a lower monthly payment. This option
works well for those pursuing careers in public service or that have lower incomes and need
assistance in making their monthly payments.

5) Extended Repayment - The Extended Repayment plan allows a borrower to stretch
their current repayment term, which is usually 10 years, up to 25 years allowing for a lower
monthly payment. Before opting to extend your repayment term, consider the impact on
your overall interest costs. Qualifications for Extended Repayment include:
The borrower must have an outstanding balance of principal and interest totaling
more than $30,000 in either FFEL or Direct Loans
All loans must have been issued on or after October 7, 1998.

Best Option For: Borrowers seeking to lower their monthly payment (without
consolidating).

Comparing Repayment Plans

The following table compares each of the major repayment plans with standard ten year
repayment. As the table illustrates, increasing the loan term reduces the size of the monthly
payment but at a cost of substantially increasing the interest paid over the life of the loan.
For example, increasing the loan term to 20 years may cut about a third from the monthly
payment, but it does so at a cost of more than doubling the interest paid over the life of the
loan. This table is based on the unsubsidized Stafford Loan interest rate of 6.8%.

Repayment Plan
and Loan Term
Reduction in Monthly
Payment
Increase in Total Interest
Paid
Extended Repayment 12 yrs 12% 22% (factor of 1.22)
Graduated Repayment 50% initial payment
38% average
reduction
89% (factor of 1.89)
Income Contingent Repayment
(salary = initial debt, 4% annual
raise)
41% declining to
33%
37% average
reduction
178% (factor of 2.78)

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For example, suppose you borrow a total of $20,000 at 6.8% interest. The following table
shows the impact of switching from standard 10 year repayment to 20 year extended
repayment.

Repayment Plan
And Loan Term
Monthly Payment Total Interest
Paid
Standard Repayment 10
yrs
$230.16 $7,619.31
Extended Repayment 20
yrs
$152.67 $16,639.74
DIFFERENCE $77.49 reduction
$9,020.43
increase

FinAid offers several calculators for evaluating the tradeoffs of different repayment plans.
Log on to www.finaid.org/calculators/.

Switching Repayment Plans

If you want to switch from one plan to another, you can do so once per year, so long as the
maximum loan term for the new plan is longer than the amount of time your loans have
already been in repayment. In other words, if you are in year 26 of a 30-year extended
repayment plan, you cannot switch to the income contingent repayment plan and have the
remaining balance written off.

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Monthly Payment Estimator

Federal Stafford Loans with 6.8% fixed annual interest

STANDARD GRADUATED EXTENDED INCOME-BASED (IBR) FORBEARANCE

Stafford
Loan
Amount
Balance at the
end of grace
or interest
capitalization
10-yr
repay
term
Years
1-4
(interest
only)
Years
6-10
25-yr
repay
term
Years
1-4
Balance
(after a 4
yr
residency)
10-yr
Standard
payment
(after 4
yrs of
IBR)
Year
1-4
Balance
(after a 4
yr
residency)
10-yr
Standard
payment
(after 4 yrs of
Forbearance)
$75,000 $82,377 $948 $467 $1,397 $572
$350-
$500
per
mo.
$83,566 $962
$0
$104,783 $1,206
$80,000 $88,276 $1,016 $500 $1,497 $613 $90,302 $1,039 $112,287 $1,292
$90,000 $100,075 $1,152 $567 $1,697 $695 $104,636 $1,204 $127,296 $1,465
$100,000 $111,875 $1,287 $634 $1,897 $776 $119,113 $1,371 $142,304 $1,638
$110,000 $123,674 $1,423 $701 $2,097 $858 $133,691 $1,539 $157,313 $1,810
$120,000 $135,473 $1,559 $768 $2,297 $940 $148,344 $1,707 $172,321 $1,983
$130,000 $147,272 $1,695 $835 $2,497 $1,022 $163,054 $1,876 $187,330 $2,156
$140,000 $159071 $1,831 $901 $2,697 $1,104 $177,809 $2,046 $202,339 $2,329
$150,000 $170,870 $1,966 $968 $2,897 $1,186 $192,598 $2,216 $217,347 $2,501
$160,000 $182,670 $2,102 $1,035 $3,097 $1,268 $207,416 $2,387 $232,356 $2,674
$162,000 $185,029 $2,129 $1,048 $3,137 $1,284 $210,382 $2,421 $235,357 $2,708
$170,000 $194,469 $2,238 $1,102 $3,297 $1,350 $222,257 $2,558 $247,364 $2,847
$180,000 $206,268 $2,374 $1,169 $3,497 $1,432 $237,117 $2,729 $262,373 $3,019

These figures are intended to provide a borrower with estimates of balances and monthly payment amounts actual amounts may vary. (Values
are rounded to the nearest dollar.) Please contact your lender/servicer(s) to discuss your balance and payment amounts.

All values above are based on the following assumptions:
Stafford loans (Federal or Direct) with a fixed interest rate of 6.8% and no fees. For all loan
amounts, $34,000 is subsidized with the remainder unsubsidized.
Four years of medical school then a 6-month grace period after graduation with the
capitalization of all accrued interest occurring at the end of the grace period
Forbearance values are based on the following assumptions:
No payment of any kind during a 4-year residency
After the 4-year residency, borrower changes the repayment option to Standard and
accrued interest capitalizes at that time

Per IBR guidelines, IBR repayment amounts are based on federal poverty
guidelines, family size, and stipend/salary.
The IBR values above are based on the following assumptions:
Family size of 1 in the 48 contiguous states
Monthly payment amounts increase gradually each year starting at an
estimated $375/month in year one up to an estimated $500/month in year
four (based on median stipend amounts from the AAMC Survey of
Resident/Fellow Stipends and Benefits). Actual monthly IBR amounts will vary
depending on borrower salary/stipend.
After the 4-year residency, borrower changes the repayment option to
Standard and accrued interest capitalizes at that time
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Federal Loan Consolidation

Consolidation Loans combine several student loans into one bigger loan from a single
lender, which is then used to pay off the balances on the other loans. It is very similar to
refinancing a mortgage. Consolidation loans are available for most federal loans, including
Family Federal Education Lending Program (FFELP), Perkins, Health Professional Student
Loans, and Direct loans.

Most FFELP lenders are no longer offering consolidation loans because these loans
are no longer profitable. Students can still consolidate their loans with the US
Department of Education's Federal Direct Loan Consolidation program at
www.loanconsolidation.ed.gov.

Interest Rates The interest rate on a consolidation loan is the weighted average of the
interest rates on the loans being consolidated, rounded up to the nearest 1/8 of a percent
and capped at 8.25%.

When to consider consolidation:
x Variable rates are low
x Multiple lenders to repay
x To obtain Public Service Loan Forgiveness
x To make Perkins loans eligible for IBR

Effects of consolidating in todays environment:
x Longer term = increased interest costs
x Possible forfeiture of borrower benefits
x Rounding may result in higher rate

Private loan consolidation BE CAREFUL
x Understand all fees and costs involved
x Do NOT include Federal Loans or all rights will be lost (tax deduction, forgiveness,
subsidies)
Forbearance

Forbearance is the period of time, often following grace or deferment, during which a
borrower may either:
x Make payments lower than those scheduled
x Delay repayment completely for a designated period of time, usually 6 months to
one year

During forbearance interest accrues on ALL loans including loans formerly subsidized, so it is
important to remember that any interest not paid during forbearance will be capitalized at
the end of the forbearance period making this a potentially costly way to postpone
payments. You must apply with your loan servicer, and they will determine the length of the
forbearance period.
Avoiding Delinquency and Default

Typically borrowers run into difficulty because they do not open their mail, do not keep in
touch with their loan servicers, or are late in filing deferment or forbearance forms.

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Delinquency means you are late in making a scheduled loan payment. A late payment
may be reported to a credit bureau, and if so, will decrease your credit score and will
remain a part of your credit history for years to come. Additionally, any borrower benefits
that you may have had will likely be forfeited.

Default means you are 270 days or more late on making your loan payment. This can
result in or more of the following actions being taken against you: immediate payment in
full, wages garnished and federal income tax returns, and even take you to court. A default
will hurt you well into the future, record of defaulted loans remains on a credit report for at
least seven years.

Heading Toward Delinquency or Default?
If you have trouble making your loan payment, contact your loan servicer(s) immediately.
Your servicer(s) knows all of the options available to you and will help you devise a plan to
avoid delinquency and default, maintain your good credit rating, and successfully complete
the repayment of your student loans.
Loan Forgiveness Programs

Public Service Loan Forgiveness

The Public Service Loan Forgiveness Program was created to encourage individuals to enter
and continue to work full-time in public service jobs. Under this program, you may qualify
for forgiveness of the remaining balance due on your eligible federal student loans after you
have made 120 payments on loans under certain repayment plans while employed full time
by certain public service employers. In general, only borrowers who are making reduced
monthly payments through the Direct Loan income-contingent or income-based repayment
plans will have a remaining balance after making 120 payments on a loan. In other words,
only borrowers with a high debt-to-income ratio or consistently very low income will qualify
for loan forgiveness under the Loan Forgiveness for Public Service Employees Program.

Effective Dates: Borrowers must have made 120 monthly payments after October 1, 2007
in the William D. Ford Federal Direct Loan (Direct Loan) Program. Therefore, the first
cancellations of loan balances will not be granted until October 2017 at the earliest.

Eligible Loans: Although loan cancellation is only available for loans made and repaid
under the Direct Loan Program, borrowers with loans made under other federal student loan
programs may be eligible if they consolidate those loans into the Direct Loan Program.
However, only payments made on the Direct Consolidation Loan will count toward the
required 120 monthly payments.

Federal Family Education Loan (FFEL) Program loans are eligible for consolidation into the
Direct Loan Program. This includes Stafford, Grad PLUS, Consolidation, Perkins and HPSL
loans.

NOTE: Borrowers may have to meet additional eligibility requirements to consolidate these
loans into a Direct Consolidation Loan. If you are unsure about what kind of loans you have
consult the National Student Loan Data System at http://nslds.ed.gov.

How do I apply for public service loan forgiveness?
Although loan forgiveness under this program is available only for loans made and repaid
under the Direct Loan Program, loans made under other federal student loan programs may
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qualify for forgiveness if they are consolidated into a Direct Consolidation Loan. To apply for
Direct Loan Consolidation log on to http://www.loanconsolidation.ed.gov.

Eligibility Requirements Repayment Plans:

To be eligible to have remaining balances cancelled, the borrower must not be in default on
the eligible loans and must have made 120 monthly payments on the eligible loan(s)
beginning after October 1, 2007. Payments must have been made under any one or a
combination of the following Direct Loan Program repayment plans:

x Standard Repayment Plan with a 10-year repayment period
x Income Contingent Repayment (ICR) Plan not available to parent Direct PLUS
loan borrowers
x Income Based Repayment (IBR) Plan not available to parent Direct PLUS loan
borrowers
x Other Direct Loan repayment plans, but only payments that are at least equal to
the amount that would be required under the 10-year Standard Repayment Plan
may be counted toward the required 120 payments.

Eligibility Requirements Employment in Public Service Job

The borrower must be employed full time (in any position) by a public service organization,
or must be serving in a full-time AmeriCorps or Peace Corps position.

For purposes of this program, the term public service organization means

x A federal, state, local, or Tribal government organization, agency, or entity
(includes most public schools, colleges and universities)

x A public child or family service agency

x A non-profit organization under section 501(c)(3) of the Internal Revenue Code
that is exempt from taxation under section 501(a) of the Internal Revenue Code
(includes most not-for-profit private schools, colleges, and universities)

x A Tribal college or university

x A private organization that is not a for-profit business, a labor union, a partisan
political organization, or an organization engaged in religious activities (unless the
qualifying activities are unrelated to religious instruction, worship services, or any
form of proselytizing) and that provides the following public services

x Emergency management
x Military service
x Public safety
x Law enforcement
x Public interest law services
x Early childhood education (including licensed or regulated health care, Head
Start, and state-funded pre-kindergarten)
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x Public service for individuals with disabilities and the elderly
x Public health (including nurses, nurse practitioners, nurses in a clinical
setting, and full-time professionals engaged in health care practitioner
occupations and health care support occupations)
x Public education
x Public library services
x School library or other school-based services
x Indian Health Service (HIS)
x Centers for Disease Control
x National Institutes of Health

Additional loan forgiveness programs:

NIH Loan Repayment Programs www.irp.nih.gov

NHSC Repayment Program www.nhsc.hrsa.gov/loanrepayment

U.S. Department of Health and Human Services
www.hrsa.gov/help/healthprofessions.htm
Loan Discharge

It's possible to have your student loan debt discharged (canceled) or reduced, but only
under certain specific circumstances:
x You die or become totally and permanently disabled

x You file for bankruptcy. (This cancellation is rare and occurs only if a bankruptcy
court rules that repayment would cause undue hardship.)

Effective July 1, 2006: A false certification discharge was created authorizing discharge if
the borrower's loan was falsely certified as a result of a crime of identity theft.

Until the discharge regulations can be developed, lenders may provide administrative
forbearance and guaranty agencies may suspend default collections if a borrower presents
evidence showing that the borrower's loan may have been falsely certified as a result of a
crime of identity theft. The lender or guaranty agency must believe the evidence is
reasonably persuasive. Note: that you can't cancel a federal student loan because you're
having some financial difficulty, unless you qualify for a bankruptcy discharge.

Applying For a Discharge
If you qualify for a loan discharge, you must apply for one:

x Federal Perkins Loan borrowers must apply to the school that made the loan or
to the loan servicer the school has designated

x FFEL Stafford and PLUS Loan borrowers should contact the lender or agency
holding the loan. You can also find a number of discharge forms online

If you're not sure what type of loan you have or who holds it, go to www.nslds.ed.gov.
The holder of your loan can answer any questions you have about loan discharge.

Making Payments on Your Loan While Your Discharge Application is Reviewed
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Until you hear whether your discharge has been approved, you should continue making
payments on your loan to prevent it from going into default or accruing (accumulating)
additional interest. However,

x If you have a FFEL Stafford Loan, you can be granted forbearance. The holder of
your Stafford Loan should grant forbearance until a decision is made on your
application. If forbearance is granted, no one is permitted to collect on your loan
until the holder of your promissory note determines whether you are eligible for a
loan discharge

x If you have a Federal Perkins Loan, schools must automatically defer your loans if
you are performing service that will qualify you for loan cancellation. You don't need
to apply for this deferment. Schools may grant such a deferment for up to 12
months at a time.

Approval of a Loan Discharge
If you qualify for a complete discharge of your loan, you are no longer obligated to make
loan payments. Depending on the type of loan discharge program you may be eligible for,
the holder of the loan may be required to refund to you some or all of the monies you paid
on the loan. In addition, the loan holder may be required to delete any adverse credit record
related to a default, and no tax refund offset or wage garnishment will take place to collect
on the discharged loan. If the loan was in default, the discharge may erase the default
status. If you have no other defaulted loans, you regain eligibility for federal student
financial assistance. Your loan holder can answer any questions you may have regarding
your eligibility for a refund.

Denial of Loan Discharge
For most all discharges, the holder of your loan makes the final decision on whether to
discharge the loanyou cannot appeal the decision to the U.S. Department of Education.
The two exceptions are false certification and forged signature discharges for a FFEL or
Direct Stafford Loan (see "School-Related Discharges" below). If you receive these types of
discharges, you may ask the Department to review the denial.

If your loan discharge is denied, you remain responsible for repaying the loan. Talk to your
loan holder about repayment options if you have a FFEL Stafford Loan. If your loan is in
default, ask about loan rehabilitation and loan consolidation.

If your school has closed, you should also explore the following options if your discharge
application is denied:
x Contact the state licensing agency and ask if there is a tuition recovery fund or
performance bond that will cover your damages based on the school closure.
x If the school filed bankruptcy, you should file a claim for your loss in the bankruptcy
proceeding. You also might want to consult an attorney about any options you may
have through the court system.

Death Discharge
Cancellation because of the borrower's death (or, in the case of PLUS Loans, the death of
the student for whom the parent borrowed) is based on an original or certified copy of the
death certificate submitted to the school (for a Federal Perkins Loan) or to the holder of the
loan (for a FFEL or Direct Stafford Loan).

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Total and Permanent Disability Discharge
Total and permanent disability is the inability to work and earn money because of an injury
or illness that is expected to continue indefinitely or to result in death.
You must submit a physicians certification of total and permanent disability. The physician
must certify that you are 100 percent disabled according to the definition of disability
above.
As of July 1, 2002, if you are determined to be totally and permanently disabled, you will
have your loan placed in a conditional discharge period for three years from the date you
became totally and permanently disabled. During this period, you don't have to pay
principal or interest. If you continue to meet the total-and-permanent disability
requirements during, and at the end of, the three-year conditional period, your loan will be
canceled. If you don't continue to meet the cancellation requirements, you must resume
payment. For more information on qualifying for this discharge, contact your loan holder.
Note: Your loan cannot be discharged because you weren't satisfied with the school's
services. Your loan can't be discharged solely because you believe the school:

x provided poor training or had unqualified instructors or inadequate equipment
x did not provide job placement or other services that it promised
x Engaged in fraudulent activities (other than falsely certifying the loan)

Also, a loan discharge cant be granted because you attended an ineligible program of study
offered by the school. The state licensing and accrediting agencies for the school are
responsible for the quality of educational services the school provides. The U.S. Department
of Education does not endorse the school's educational programs or guarantee the school
will deliver the services for which a student contracted.
Maintaining Financial Records

You have received a lot of paperwork over the years from your lenders and servicers, before
you pack up and move, take the time to organize your financial aid paperwork. The
following are suggestions to assist you in organizing your borrowing portfolio:

Keep up with your exit interview information: Prior to graduation from school, you will
receive detailed accounting of all your educational loans. Keep this information with you, not
in Moms attic or in a storage unit somewhere. Be sure that the information makes every
move with you throughout your years of repayment, residency, fellowship, and/or practice.

Keep up with your mail: As previously noted, open and read all your mail when it arrives.
Do not miss a deadline or a notice regarding a change in the status of your loans by tossing
an unopened envelope into a drawer or a box. Lenders expect you to stay abreast of the
details regarding your loans. Missing a deadline can eventually throw you into a default
status.

Set up a logical filing system that works for you: Up to now, you have probably filed all
your financial aid papers by academic year so they would be easy to refer to while you were
in school. It is time now to change that filing system so that it will help you remain aware of
lenders and due dates. Make a file folder for each lender/servicer. (Note: you may deal with
a servicer hired by your lender to service your loans). Put into this file the promissory note
and other papers relating to each loan you received from that lender. Keep a record of each
lenders address and phone number(s) in the file.

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Keep accurate, complete records: Put a log sheet into each lenders file, and use it to
make notes about every phone call you make or receive and each form you mail to the
lender/servicer. Jot down the date, amount, and number of the check you write when you
make every payment. These canceled checks can prove when payments were made, and
they may be essential for taking advantage of tax benefits for loan repayment. Keep track
of the dates, the names of people you contact, what was discussed, and who is supposed to
do what next. Knowing the name of the person you spoke with the first time will make
follow-up calls easier and less stressful for you and for the customer service representatives
as well.

Always, always keep a photocopy of any form you mail to your lender/servicer. Note the
date when you mailed it. Consider using registered mail, and a return reply card, so that
you know when your mail was delivered and who signed for it. This may require a little
more time and a little extra expense up-front, but it may save you lots of money and
anguish later on.

Set up a long-range calendar: Set up a calendar that covers at least enough years to get
you through residency. Mark on the calendar the dates you need to submit forbearance or
deferment forms. Keep in mind that grace periods and deferments vary in length.
Remember that most forms must be submitted annually, and you are not likely to get a
reminder from your lender/servicer. Do not wait to request school/hospital forms. Keep this
calendar in a prominent place, and make a habit of referring to it regularly.

Keep your lenders/servicers informed of changes: Be certain that you notify your
lender/servicer when you change your address, telephone number, or name. Undeliverable
mail can quickly become stumbling blocks for your financial future.

Student Loans and Your Credit Rating

Your student loans are reported to the three national credit agencies. It is important to
understand that if you are late in filing paperwork or making a payment, your delinquency
will be reported.

How do I obtain a credit report?
Consumers have the opportunity to receive free credit reports once a year from the Annual
Credit Report Request Service. This is the only centralized credit reporting service
authorized by Equifax, Experian and TransUnion to provide free credit reports. Dont
confuse this program with the many paid services available to consumers to monitor your
credit, or the now antiquated services that provide you with credit reports from all three
agencies at one low price. You can go online to request, view, and print all three free
credit reports: www.annualcreditreport.com

FICO fundamentals:
A FICO score is a three-digit number that determines the interest rate you will pay on your
credit cards, car loan, and home mortgage, as well as whether you will be able to get a cell
phone or have your application for a rental apartment accepted. FICO stands for Fair Isaac
Corporation, the firm that created the formula that seems to lord over your financial life.
The way the business world sees it, your FICO score is a great tool to size up how good you
will be at handling a new loan or credit card, or whether youre a solid citizen to rent an
apartment to. A high FICO score gives you a great reputation with the business world; youll
get the best deals. A lower FICO score translates into paying higher interest rates on cards
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and loans. Your credit history can even affect your auto insurance premiums or your ability
to get that job you applied for.

Your: Accounts for this
percent of your FICO
score
Record of paying your bills on time (payment
history)
35
Total balance on your credit cards and other
loans compared to your credit limit
30
Length of credit history 15
New accounts and recent applications for credit 10
Mix of credit cards and loans 10

Fair Isaac uses a formula to come up with a score for you that can range from 300 to 850.
Anything between 300 and 500 means you are a toxic financial risk and you are going to be
hard-pressed to find any business that will want to work with you. Scores between 500 and
850 are sliced and diced to fall into six ranges; the exact cutoffs for those ranges can vary
from lender to lender, but typically this is what you may encounter.

The FICO Ranges
720-850 Best
700-719
675-699
620-674
560-619
500-559 Worst

The range your score falls into ultimately determines the interest rate that you will pay on
loans. Other factors, such as your employment history and salary, will affect the deal you
get, but your FICO score is a major component in determining the interest rate you pay.

How will consolidation impact my credit rating?
Your new consolidation loan will be reported to the credit agencies. It is important that you
verify that your credit report was correctly updated. The loans you consolidated should
show a $0 balance, as these loans were paid off by your consolidation loan. If the credit
report does not show a $0 balance, it will appear that you have double the amount of
student loans. Your total debt burden is a part of your overall credit rating, and therefore
this mistake could impact your credit score.

What should I do if there is an error on my credit report?
If you find an error on your credit report, contact the appropriate credit agency directly:
Equifax (800) 685-1111 www.equifax.com
Experian (888) 397-3742 www.experian.com
TransUnion (800) 888-4213 www.transunion.com

These credit bureaus do not cross verify information, so errors may exist on one but not the
other. Submit a dispute to each credit bureau and the lender who provided the erroneous
information. You should get copies of all three credit reports, and report errors immediately
and dispute each one separately. Agencies are required to investigate/respond within 45
days.
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Selecting a Financial Advisor

You may be considering seeking help from a financial planner for a number of reasonsfor
example, deciding whether to buy a new home, setting up a practice or partnership,
planning for retirement or your childrens education, or, more commonly, simply not having
the time or expertise to keep your finances in order. Whatever your needs or reasons,
working with a financial planner is a helpful step in securing your financial future.

There are several questions you should ask, and steps you can take on your own, before
choosing the financial planner who will help you meet your short-term needs, as well as
your long-term goals. Asking the right questions and following these steps should result in a
successful partnership.

What experience do you have?

Find out how long the planner has been in practice, as well as the number, and types, of
companies he or she has worked with. Choose a planner with a minimum of three years
experience in counseling individuals on their financial needs. Most importantly, you want to
choose a planner who has extensive experience in, if not specialization in, working with
physicians.

What are your qualifications and credentials?

Many financial professionals use the term financial planner. Ask the planner whether he or
she holds a financial planning designation, such as CLU (Certified Life Underwriter), ChFC
(Chartered Financial Consultant), CFP (Certified Financial Planner), RIA (Registered
Investment Advisor), or PFS (Personal Financial Specialist). If the planner holds one of
these designations, check on his or her background with the CFP board or other relevant
professional organization. You may also ask for references, from current clients and other
professionals, such as accountants and attorneys that the planner has worked with. Find out
if the planner has ever been fined, reprimanded, or suspended by contacting your State
Insurance and Securities Departments, the NASD, or the SEC

What services do you offer?

These will vary, depending on a number of factors, including professional credentials,
license, and areas of expertise. Ask yourself if this planner offers services that are
compatible with your immediate and long-term needs. Review a sample of a completed
plan, to determine whether the planner offers the particular services that meet your
personal financial needs.

What is your approach to financial planning?

Ask the planner about the types of clients and financial situations that he or she typically
likes to work with. Make sure the planners viewpoint on investing is not too cautious, or too
aggressive, for you.

Will you be the only person working with me?
The planner may work with you alone, or have others in the office assist. You may want to
meet everyone who will be working with you. If the planner works with professionals outside
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his or her practice (e.g., attorneys, insurance agents, tax specialists), get a list of their
names and check on their backgrounds.

How will I pay for your services?

Planners can be paid in several ways. They can be salaried, commission-only, fee-only, or
compensated through some combination of commission and fee. As part of your financial
planning agreement, the planner should disclose to you clearlyin writinghow he or she
will be paid for the services to be provided.

How much do you typically charge?

While the amount you pay will depend on your particular needs, the planner should be able
to provide you with an estimate of possible costs, based on the work to be performed.

Could anyone besides me benefit from your recommendations?

Some business relationships that a planner already has in place could bias his or her
professional judgment while working with you, thereby inhibiting the planner from acting in
your best interest. Ask the planner to provide you with a written description of his or her
conflicts of interest. Dont hesitate to walk away from any planners who promote only their
own financial products, or those of the companies with whom they have a business
relationship or partnership.

Can I have it in writing?

Ask the planner to provide you with a written agreement that details the services that will
be provided. Keep this document in your files for future reference. A qualified financial
planner will have a proven track record, and should welcome these questions. Its critical to
feel confident that you can trust the planner to handle your personal/business finances in an
ethical, confidential manner. Keep in mind that you want to be working with this person for
many yearsperhaps, for the rest of your life. Above all, you should feel comfortable in the
relationship.

To check the professional record of a financial planner, contact:

x Certified Financial Planner Board of Standards, Inc.
800-487-1497 www.cfp.net

x North American Securities Administrators Association
202-737-0900 www.nasaa.org

x National Association of Insurance Commissioners
816-842-3600 www.naic.org

x National Association of Securities Dealers - FINRA
301-590-6500 www.finra.org

x Securities and Exchange Commission
888-SEC-6585 www.sec.gov

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To find a financial planner in your area, contact the following organizations:

x Financial Planning Association
800-322-4237 www.fpanet.org

x National Association of Personal Financial Advisors
847-483-5400 www.napfa.org

x The Society of Financial Service Professionals
610-526-2500 www.financialpro.org

Educational Tax Benefits

The Lifetime Learning Tax Credit

The Lifetime Learning credit is available for all types of post secondary education, unlike the
other credits. Use the Lifetime credit once you have exhausted your eligibility for more
advantageous credits. This credit may be particularly helpful to graduate students.

You can claim a tax credit of up to $2000 per tax return (not per student). The maximum is
$4,000 if at least one family member was a student in a Midwestern disaster area school.
The qualifying student(s) can be anyone in the family. The Lifetime Learning credit is non
refundable the maximum credit that you can receive is limited to the amount of tax you
owe. You are eligible for the credit if your modified adjusted gross income is $60,000 or less
(for married couples filing a joint return, $120,000 or less).

Qualifications:

x Expenses that count towards this credit are tuition, fees, and amounts required to be
paid to the institution for books, supplies and equipment (less the amount of certain
scholarships and grants received) during 2009 for yourself, your spouse, or someone
whom you claim as a dependent on your tax return. If a student attended school in a
Midwestern disaster area, other expenses may be included.

x You don't have to be pursuing a degree or certificate to qualify for the Lifetime Learning
Credit. You can claim it for all years of post secondary education and for courses to
acquire or improve job skills.

x You must file a federal income tax return and have a 2009 income tax liability of any
amount to get the credit. If you are claimed as a dependent on someones tax return,
only the person who claims you can apply for the credit.

x If you claim the American Opportunity credit or the Hope credit for one or more
students in your family, you can't use their expenses to figure your Lifetime Learning
Credit. You can still take a Lifetime Credit for family members for whom you are not
claiming the other credits.

Unlike other credits, students who have felony drug convictions do qualify to take the
Lifetime Learning credit.

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How to Claim Tax Credits
To claim any of the three tax credits, you must report the amount of your qualified
expenses (less certain scholarships, grants, and untaxed income) on IRS Form 8863 -
Education Credits. Complete instructions for using this form and more details are available
from the IRS.

Tuition and Fees Tax Deduction
The Tuition and Fees tax deduction can reduce your taxable income by as much as $4,000.
This deduction may be helpful to you if you are not eligible to take one of the tax credits. It
is taken as an adjustment to income, which means you can claim this deduction even if you
do not itemize deductions on Schedule A of Form 1040.

You are eligible to take the deduction if your modified adjusted gross income is $80,000 or
less ($160,000 if filing a joint return). The amount of the Tuition and Fees deduction you
are eligible for depends on the amount of qualified tuition and related expenses paid for
eligible students.

Tuition and Fees Tax Deduction Qualifications:
x Expenses that you can deduct are tuition, fees, and amounts required to be paid to the
institution for books, supplies and equipment (less the amount of certain scholarships
and grants received) during 2009 for yourself, your spouse, or someone whom you
claim as a dependent on your tax return. The expenses must have been for a student
enrolled in one or more courses at an eligible* educational institution.

x You can't claim both an education credit and the tuition and fees deduction for the
same student for the same year, but you can take the deduction for one student and a
credit for another.

x You can't take this deduction if you deduct tuition and fees expenses under any other
provision of the law (for example, as a business expense).

x You can't claim this deduction if your filing status is married filing separately or if
another person can claim you as a dependent on his or her tax return.

Student Loan Interest Deduction
The Student Loan Interest tax deduction can reduce your taxable income by as much as
$2500. It is taken as an adjustment to income, which means you can claim this deduction
even if you do not itemize deductions on Schedule A of Form 1040.

You can deduct interest paid on a student loan for yourself, your spouse, or your
dependents. You are eligible to take the deduction if your modified adjusted gross income is
$75,000 or less ($150,000 if filing a joint return). The amount of the Student Loan Interest
deduction you are eligible for depends on the amount of interest paid and your income.

Qualifications:
x Qualified student loans must have been used to fund educational expenses such as
tuition, room and board, fees, and books for a student enrolled at least half-time and
pursuing a degree, certificate, or similar program at an eligible* institution.

x You cannot claim this deduction if your filing status is married filing separately or if
another person can claim you as a dependent on his or her tax return.

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Taxability of Loan Forgiveness Programs

If you've received a student loan that states it can be forgiven, cancelled, or paid if you
work for a certain period of time, in certain professions, for any of a broad class of
employers, then the amounts forgiven may qualify for tax-free treatment.

For complete information on educational tax benefits, see the IRS Publication 970 on the
IRS website: www.irs.gov.

*An eligible educational institution is any college, university, vocational school, or other post
secondary educational institution eligible to participate in a student aid program
administered by the U.S. Department of Education. According to the IRS, "it includes
virtually all accredited, public, nonprofit, and proprietary post secondary institutions." The
educational institution should be able to tell you if it is an eligible educational institution.
Certain educational institutions located outside the United States also participate in the U.S.
Department of Educations Federal Student Aid (FSA) programs

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Resources and Definition of Terms/Conditions

The following is a list of helpful links. When in doubt, these experts can help you sort
through all your financial questions.

Accountants:

American Institute of Certified Public Accountants
http://www.aicpa.org/yellow/ypascpa.htm

Automobiles:

Kelley Blue Book
www.kbb.com

Edmunds.com
www.edmunds.com

Bonds:

Bond Market Association
www.investinginbonds.com

Financial Calculators:

Nolo's Plain English Law Centers
www.nolo.com

FinAid
www.finaid.org/calculators

Sallie Mae
www.salliemae.com/tools/calculators/repayment

Data Masters: This calculator provides salary and cost-of-living calculators
http://www.datamasters.com/

Financial Planners:

Financial Planning Association (FPA)
www.fpanet.org/plannersearch/plannersearch.cfm

National Association of Personal Financial Advisors (NAPFA)
www.napfa.org

House Stipend Survey:

http://www.aamc.org/data/stipend/2009_stipendreport.pdf

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Insurance:

Insurance Information Institute
www.iii.org

Interactive Budget Worksheet:

http://www.aamc.org/programs/first/facts/budget_worksheet.pdf

Interest rates:

Bankrate.com
www.bankrate.com

WebMath.com
www.webmath.com/simpinterest.html

Lawyers:

Martindale-Hubbell's Martindale.com
http://lawyers.martindale.com/marhub
Search for a lawyer in your area, by name, by specialty, by firm, and more.

Money-Market Rates:

iMoneyNet;www.ibcdata.com
Search for the best money-market mutual fund rates, both taxable and tax-free; learn the
basics of money-market fund investing.

Mortgage Calculators:

Interest.com
www.interest.com/calculators

HSH Associates, Financial Publishers
www.hsh.com/calculators.html

Mutual Funds:

Morningstar.com
www.morningstar.com

Savings Bonds and Treasuries:

US Department of the Treasury's Bureau of the Public Debt
www.publicdebt.treas.gov

State Insurance Departments:

National Association of Insurance Commissioners
http://www.naic.org/state_web_map.htm
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Stocks:

Quicken
www.quicken.com/investments

Morningstar.com
www.morningstar.com

Taxes:

Internal Revenue Service
www.irs.gov

Zero-Coupon Bonds:

Bonds Online
www.bondsonline.com/asp/treas/zeros.asp

Glossary

Borrower The person who receives the loan.

Capitalized Interest Accrued interest added to the outstanding principal. Subsequent
interest accrues on the new total principal balance, which includes any capitalized interest.

Consolidation Refinancing multiple education loans into a single new loan. This can
result in a different interest rate and/or longer repayment period.

Co-signer A creditworthy individual who agrees to be responsible for repaying a private
loan if the primary borrower does not. A loan borrower who is not eligible on the basis of
their own credit may become eligible with a co-signer. The co-signer must be a U.S. citizen
or national, a U.S. permanent resident, or other eligible non-citizen.

Cost of Attendance (COA) The total cost of attending a post-secondary institution for
one academic year. The budget usually includes tuition, fees, room, board, supplies,
transportation, and personal expenses.

Credit Check The process of obtaining information about an individuals borrowing habits
and money-management skills. Lenders use credit reports to determine if they should
approve a loan and to set the terms (interest rate, fees, and length) of the loan.

Default A failure to repay a student loan according to the agreed-upon terms of a
promissory note.

Deferment The temporary postponement of payments on a loan. Subsidized loans,
including Perkins Loans, will not be charged interest during the deferment. Unsubsidized
loans will continue to accrue interest during the deferment. Unpaid interest will be
capitalized and increase the amount that must be repaid.

Delinquent The status of a loan that begins the day after the due date of payment when
the borrower fails to make the equivalent of one full payment.

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Electronic Signature The process by which a document is signed via the Web.
Submitting an electronic signature eliminates the need to print and mail the document and
expedites the approval process.

Endorser A creditworthy individual who agrees to be responsible for repaying a Federal
PLUS loan if the primary borrower does not. A PLUS loan borrower who is not eligible on the
basis of their own credit may become PLUS eligible with an endorser. The endorser must be
a U.S. citizen or national, a U.S. permanent resident, or other eligible non-citizen. The
dependent undergraduate student for whom a parent is pursuing a PLUS loan cannot be the
endorser.

Endorser Addendum An addendum to the Federal PLUS Loan Application and Master
Promissory Note (MPN) signed by the borrower of the Federal PLUS Loan. When signing the
Addendum, the endorser is agreeing to repay only the loan that is identified in the
addendum, if the borrower does not repay the loan.

Expected Family Contribution (EFC) The amount a family is expected to contribute to
a student's education. Expected family contribution is calculated based on family earnings,
net assets, savings, and size of family and number of students in college. Graduate students
are considered Independent so the EFC is based solely off of the students earnings, net
assets, savings, and size of family.

Federal Default Fee The fee that guarantors are required to deposit into a federally-
owned reserve fund. This fee is used to reserve funds to reimburse lenders if a student or
parent borrower fails to repay a loan.

Federal PLUS Loan A low interest federally sponsored loan available to credit eligible
graduate students and credit eligible parents of undergraduate dependent students.

Federal Stafford Loan A federally guaranteed loan program that allows students to
borrow funds. Stafford loans allow a student to defer payments while they are in school.
Stafford loans can be either subsidized or unsubsidized.

FFELP Federal Family Education Loan Program. A federal student loan program that
provides students and their parents with access to low cost student loans, including
subsidized and unsubsidized Federal Stafford loans, Federal PLUS loans, and Federal
Consolidation loans.

Forbearance A temporary cessation or reduction of payments due to financial difficulty.
The borrower is responsible for all accrued interest during a forbearance period. Unpaid
interest may be capitalized quarterly or at the end of the forbearance.

Free Application for Federal Student Aid (FAFSA) The application for federal student
financial aid, processed at no cost to the applicant. It is used to determine a students
eligibility for federal grants, loans and work-study.

Guarantor or Guarantee Agency The state agency or private non-profit institution that
has an agreement with the U.S. Secretary of Education to administer a loan guarantee
program under the Higher Education Act.

Interest A fee charged to the borrower for use of a lender's money.
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Lender The institution that originates your funds.

Master Promissory Note (MPN) A contract the student signs when taking out either a
Federal Stafford or Federal PLUS loan. The Federal Stafford MPN is used for the subsidized/
unsubsidized loans the student may receive for the same enrollment period. If the student
is attending a four-year or graduate school, the Federal Stafford MPN or Federal PLUS MPN
also covers loans of the same type the student may receive for future enrollment periods.

Origination Fee A fee withheld from the principle disbursement amount by the lender at
each disbursement of funds to the school to cover the costs of originating the loan.

Private Loans A type of loan that provides supplemental funding when other financial aid
does not cover costs. Banks or other financial institutions and schools offer these loans (not
sponsored by government agencies).

Promissory Note A legally binding agreement the borrower signs to obtain a loan, in
which the borrower repays the loan (with interest and applicable late fees and/or collection
costs) in periodic installments. The agreement also includes information about any grace
period, deferment, or cancellation provisions and the borrower's rights and responsibilities
in respect to the loan.

Servicer The institution that you will work with in repayment (i.e. where you will make
payments, file deferments, etc.).

Subsidized Loan A need-based loan which is eligible for interest benefits paid by the
federal government. The federal government pays the interest that accrues on subsidized
loans during in-school, grace, authorized deferment, and (if applicable) post-deferment
grace periods if the loan meets certain eligibility requirements.

Unsubsidized Loan A non need-based loan which accrues interest from the date of
disbursement until the loan is paid in full. The borrower is responsible for repaying the
interest on an unsubsidized loan during in-school, grace, and deferment periods, in addition
to repayment periods.

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Podiatry School Financial Aid Offices

BUSGMS NYCPM
305-899-3123 212-410-8006
www.barry.edu/podiatry www.nycpm.edu

CSPM OCPM
510-869-1550 216-231-3300
www.samuelmerritt.edu/podiatric_medicine www.ocpm.edu

CPMS TUSPM
515-271-1470 215-625-5447
800-240-2767 x-1470 http://podiatry.temple.edu
www.dmu.edu/cpms

SCPM AZ MIDWESTERN
847-578-3217 623-572-3321
www.rosalindfranklin.edu/scholl www.midwestern.edu

WESTERN
800-346-1610
www.westernu.edu

Works Cited

FinAid. 1994. December 2009 <www.finaid.org>.

Orman, Suze. "Young, Fabulous and Broke." Orman, Suze.

U.S. Department of Education. 2/26/10. <www.studentaid.ed.gov>.

Important: All information and estimates are based on interpretation of federal regulations
as of December 2009 and are subject to change. These are estimates only. Graduates
should always contact their lender/servicer(s) to discuss exact loan balances and repayment
options.

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The APMSA extends its appreciation to the
American Academy of Podiatric Practice Management
(AAPPM) and the following contributors:

John Guiliana, DPM, MS
Jason Kraus
Jane Graebner, DPM
Kris Titko, DPM
Gayle Johnson, PMAC
Jeffrey Lafferty, JD
Charley Greiner, DPM
Bill McCann, DPM
Ray Posa, MBA
Gayle Johnson, PMAC
Louis DeCaro, DPM
Mike Crosby, CPA
Hal Ornstein, DPM
Jeffrey Frederick, DPM
Jasen Langley, DPM
Phillip Ward, DPM
SuEllen Dercher
Josh White, DPM, CPed
David Dercher
Rich Levin, DPM
Mark Sherrod
Peter Paicos, DPM
Jeff Lafferty, JD
Kevin McDonald, DPM
Debra Womick, DPM
Les Appel, DPM
Charles R. Young, DPM
Barry Mullen, DPM
Meri Kuvent
Bob Kuvent, DPM
Craig Thomajan, DPM
Animesh Bhatia, DPM
Youve learned how to be a great doctor
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For more information on the many benets of AAPPM membership, or
about the Practice Management Club at your school, visit www.AAPPM.org.
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121

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Security Policies and Procedures The Final Hurdle

The Centers for Medicare and Medicaid Services (CMS) has released an introductory
overview of the Health Insurance Portability and Accountability Act (HIPAA) 5010. The
implementation of HIPAA 5010 will require changes to the software, systems, and perhaps
procedures that physicians use for billing Medicare and other payers. It is essential that
DPMs are aware of these HIPAA changes and that they plan for their implementation.
The best way to address HIPAA compliance is to treat the regulation as a single
integrated entity. By keeping your eye on the total picture, you wont have to waste time,
effort and money to readdressing items at a later date. You should have a total integrated
HIPAA plan and work it into your daily routine. Make it second nature and compliance will be
much less burdensome.

While the privacy requirements lend themselves well to boilerplate policies and
procedures requiring only minor adjustments for your practice; Security will be a horse of a
different color. The security requirements are so specific to your practice that writing
policies and procedures to address security issues in your practice will require much more
thought and effort.

With HIPAA privacy components, most offices only had to take existing ways of doing
business and put it in writing, print up their NPP, display it in the waiting room, post it on its
web site and distribute to patients; done. Security on the other hand will require much
more. Security is going to get into areas that most practices have never thought of and
dont even have a foundation to build on. Security will deal with the physical facility, the
computer system, computer user procedures and practice contingency plans among others.

While many have accomplished the privacy portion of HIPAA without conducting a
Gap analysis; with the security portion a Gap analysis will be essential for the following
reason: Privacy compliance required little or no expenditures in order to be compliant,
security however may require investing quite a bit of money in software, hardware and
facilities upgrades. By conducting a Gap analysis you can identify areas needing attention
and then work out a long term plan to address these issues. The key here is that you are
proactive. You have identified and are working toward mitigating the problem areas. That
being said, if there is a breach in your security you are still responsible. The difference is in
the amount of your liability. If you have identified problem areas and have an existing plan
to address then you will be in a better position than being caught with a security breech and
having no knowledge of the breech, or corrective plans. Again we come back to our favorite
HIPAA buzz word MITIGATION. HIPAA is all about making reasonable efforts to reduce the
risk of having PHI falling into the wrong hands.

The requirements for compliance under the security provisions of HIPAA, unlike
privacy which many practices took a cookie cutter approach to, will be so practice specific
that it is unlikely that you will be able to meet the requirements with anything less than a
well executed, highly individualized policy and procedures manual. Some of the areas that
must be addressed are data backups, intrusion detections / prevention and access control to
data.

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Data Backups

Have you ever thought about a parachute? Its a nice invention. Could you image
having to wear one all the time? It would be cumbersome and awkward, but could you
imagine not having one when jumping from an airplane. Computer backup systems are the
same way. They can be a nuisance and a bit of a bother, but like a parachute when you
need one nothing else will do.

I have seen so many cases over the years where clients blindly put tapes into their
backup units, assume they work and the next day switch tapes and just go about their
business. As a matter of sound business practice you need to test and verify your backups
to make sure that they are actually backing up your data properly and the information is
without errors.

Under HIPAA security rules, not only are you required to perform regular backups
but you are also required to test and verify that the backup was successful. Also, you must
also have a procedure to make sure you can restore the data and you must also have a
provision to ensure you keep a copy safe and off site.

Conventional tape backups are fairly easy to use but making sure that they are
meeting the contingency requirements of HIPAA can be a laborious effort for your staff and
may even be beyond what the staff can do.

To every HIPPA problem there seems to be a HIPAA solution. Actually, this solution
has been around for several years but is now finding a new niche in the medical field,
especially in small offices, where data backup is essential. There are many companies
offering web based backup services. The services operate in the following manner: special
client backup software is installed on your computer; the software runs a batch of data
every night, similar to how a tape system operates; the backup software takes the backup
data and compresses it, while performing a 428-bit data encryption; the compressed and
encrypted data is then sent to a remote server, where it is received and processed; to verify
the data, the remote server opens the files and compares it to a known copy in your folder;
the server then recovers a file from your backup to ensure file integrity; the remote server
then compiles a report including all integral information pertaining to your backup and e-
mails you a report. Daily, you will receive e-mails confirming that the data backup has been
done successfully, and that the data can be restored.

These services address several points of concern in HIPAA security compliance. They
provide a safe, hands off approach to backing up your data, they keep your data safe and
off-site, they provide you with documentation that you are meeting and exceeding the
HIPAA mandates, and they relieve your staff of the responsibility of performing the backups.

Anti-Virus Software and Operating System Patches

Anti-virus software is so essential in todays computer environment; so much so that
I tell clients to not even bother running their PCs if they are not running up-to-date virus
software. Why, because viruses are so prolific that in a very short time you WILL get one.
Anti-virus vendor watchdog groups are reporting that new virus activity was up 17.5
percent over the past six months, and viruses are getting more sophisticated, with more
sophisticated targeting.

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Just to demonstrate this fact for my clients, my anti-virus program has an audible
alert option that I can switch on for demonstration purposes; it goes off every time a virus
attempts to enter my system. When activated, it will beep every 5 to 10 seconds all day
every day, thats how prominent viruses are in todays world.

Some users believe it wont happen to them or they cant afford the software or the
update subscriptions. The cost of repairing a system after being infected will cost much
more than even the most expensive anti-virus software; plus you cant even put a monetary
value on the cost of lost data. I consider the money paid for anti-virus software to be part of
the operating expense of a computer, just like electricity.

Under HIPAA security requirements you are required to safeguard your systems from
outside intrusion and failing to do so is a violation. Virus attacks and outside hacks are
considered common knowledge and you are responsible to implement procedures to
prevent intrusions. Just installing anti-virus software is not enough. You must configure it
so that it will quarantine the virus and /or delete it. You need to also make sure the virus
patterns that the manufacture provides are up to date.

Once you have your anti-virus software installed and configured and getting its
updates, youre done, right? Wrong. There is another key component that must also be
done; that is updating your operating system. You should be checking for Windows updates
on a daily basis. In Windows 98 and later, Windows has a scheduler feature whereby
Windows will automatically go to the Microsoft update site and find any new critical updates
and download them for you. It will then have a little pop up alert letting you know that the
updates are downloaded and ready to be installed.

This is important because many viruses are written to exploit vulnerabilities in
Windows. Even though you have anti-virus software if you have critical holes in Windows
you are still subject to getting a virus. The anti-virus software also depends upon the
operating system being secure.

Firewalls

In addition to anti-virus software to keep out malicious email and software attacks,
Firewalls keep out direct intrusions as well as blocking some virus exploits. The firewall is
one of the most overlooked pieces of security. Firewalls are designed to prevent
unauthorized access to your computers from the web.

The broadband explosion has provided Internet users with a better, faster solution
than the traditional dial-up connections we've been used to. That's the good news. The bad
news is broadband connections have some drawbacks, the most serious of which is the fact
that they are "always on." A connection that never shuts off is a hacker's dream. Hackers
like "always-on" connections like DSL, cable modems and T1 lines because they're always
there and they're predictable. This isn't to say that broadband connections are bad--quite
the contrary. Broadband is a great technology. Users just need to make sure they're using
the appropriate level of protection that a firewall solution can offer.

Without a firewall in place hackers can access your PHI and either use it for their
own purposes or disseminate it to the world at-large. Firewalls are a great way to protect
your practices computers from intruders. They are designed to defend against attack by
implementing a series of rules that permit, or deny, traffic to pass between your network
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and the Internet. Based on the way these rules are set, the inbound and outbound flow of
information maybe extremely tight or very relaxed. The trick is to maintain a balance
between your practices need for security and your employees' need to get their work done
without interference.

Firewalls are absolutely necessary and are not very expensive. I would strongly
suggest having the firewall installed by an expert. While anyone can take it out of the box
and plug it in. The trick is to configure it properly or it becomes a useless piece of hardware
sitting on your network not protecting you and only providing you a false sense of security
until your network is compromised.

Access Control Using Biometrics

Biometrics are any security device that uses unique physical attributes of the user to
identify themselves. There are currently face scanners, palm scanners, retina scanners and
finger print scanners on the market today. For our purposes I will contain this discussion to
finger print scanners. The finger print scanners are the least expensive of the biometric
devices yet still offer outstanding security.

The way the fingerprint biometric systems work is as follows. The scanners come
bundled with security software that acts as an overlay on your desktop. The software
intercepts the login procedure and requires a fingerprint input in order to proceed. The
software also has a registration process that scans each persons fingerprints and digitally
records the fingerprints as an algorithm, so it never keeps a "picture" of your actual
fingerprint. The scanning software then works in conjunction with the Windows operating
system security and allows you to assign rights and permissions to each user. It is really a
fascinating piece of technology.

Under the security rules of HIPAA, you are required to secure all your computers by
the following means:

1). Each user has their own unique login name and password of a minimum of 6
characters.
2). No users shall know or use another person's password.
3). The passwords must be changed at least every 90 days.
4). The passwords must have the proper access level assigned to them based upon the
persons job function.

The reality of the situation is that if you use complex passwords and change them
frequently, people will forget them; then the system administrator has to recreate the users
account and setup a new password. Worse yet, if they can't remember the password, they
will write them on a sticky note and put them where they can find it easily, like on the
screen. Also in a small office, people are close and share information and they will share
their passwords. By using the fingerprint scanners you eliminate all of that and actually
make logging in fast and easy. The person just touches the fingerprint scanner and in about
a second they are logged in. It takes no thought, just press and go. The scanner's software
knows who it is that is logging in and gives them the rights and permissions that they are
allowed. You can't lose your password, you can't forget it, and you can't give it to someone
else.

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Access Control to Discarded PHI - Office Shredders

One of the most overlooked security flaws in a practice is the waste paper basket. If your
office is not currently using a shredder then please by all means at the end of the day take
a look through your waste paper basket, especially at the front desk. You may find an
abundance of PHI in there. You may think that this is a bit paranoid to go through the trash,
but in Philadelphia there was a crew that was working with insiders in an HMO and they
were putting patient PHI in the trash. Their accomplices would then go through the trash
and remove the PHI, and then was set up with some very elaborate devices for making
forged credit cards and documents. This crew would then open charge cards, make
mortgages and even purchase automobiles all with the forged documents. The bottom line
is that the HMO will have serious liability because they have an obligation to HIPAA policies
and procedures in place to prevent this kind of activity.

The Final Step Keeping It All Together

The most effective way to keep track of your HIPAA data is with the use of a HIPAA tracking
tool. There are many good one on the market. Look for a tool that provides a thorough
review of your practice of every section of the HIPAA regulations. Make sure it produces Gap
analysis reports, year to year trending reports, mitigations action plans, work flow plans,
incident tracking and graph reports showing all results. In the final phase of HIPPA you will
find that an electronic HIPAA compliance tracking tool will be worth its weight in gold.

For more information contact:

The American Podiatric Medical Association
800-275-2762
www.apma.org

CMS HIPAA Site: http://www.cms.hhs.gov/hippa/hipaa2/default.asp

HIPAAlert: http://www.hipaadvisory.com/alert

American Public Health Association/APHA and APMA
page
b/w
p/u 10

Joining APHA
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and healthy.
Join The Podiatry
Section Today at
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Taking the Mystery Out of OSHA

The Occupational Safety and Health Administration (OSHA) was created to ensure safe
workplace conditions for employees of all industries, including health care. Employers who
dont comply with OSHA regulations will pay the penalties in both time and money. An
employer who knowingly falsifies OSHA records faces a possible $10,000 fine and up to six
months in jail, for example. Other violations carry fines as high as $70,000, depending on
whether the violation was willful. In addition, the legal fees an employer incurs when
contesting a fine often total tens of thousands of dollars depending on the complexity of the
legal issues involved and the duration of representation.

For podiatrists, OSHA doesnt have to be a mystery. Officials at the Occupational Safety
and Health Review Commission (OSHRC), which enforces OSHA regulations and adjudicates
disputes, insist that their agency is not interested in staging witch hunts. OSHRC is
physician-friendly, says Linda Whitsett, the agencys director of public affairs. She explains
that just as OSHAs purpose is to prevent workplace injuries, OSHRC would rather foster
good-faith compliance than issue fines. And OSHRC, a relatively young agency that has
endured its share of growing pains, has heard numerous complaints from managers in
private industry about its modus operandi over the past decade. OSHRC has thus instituted
changes to make compliance easier.

For one, OSHA regulations are now written in plain English, not in legal jargon, so that any
worker or employer can quickly interpret them. The agency also has implemented a
phone/fax response line for small businesses. A podiatrist who has a complaint filed against
him/her can now fax evidence to OSHRC to attempt to prove that his/her practice is
complying.

You can make OSHA regulations appear even less intimidating just by becoming more
familiar with them. For the sake of discussion, OSHAs purview can be divided into the
following three categories: general standards, health care standards and the unknown.

General Standards
There is some confusion about which occupational incidents need to be documented, partly
because the regulations define only certain events as reportable. To be safe, you should
report all events, from those requiring medical attention to those involving routine first aid.
When in doubt, report.

Also, guard yourself and your staff from the obvious sources of potential danger. Equip
your practice with safety eyewear, footwear, hand protection, respiratory aids, back
protection, railings on stairs, safety clothing and other protective gear as necessary. Then
turn your attention to the less obvious breeding grounds for danger, such as parking lots,
break rooms, elevators and hallways. Because OSHA compliance is an ongoing
responsibility, you must check and maintain your safety equipment periodically. Store and
use all chemicals, including cleaning products, in a safe spot according to directions on the
label to avoid injury. To further ensure protection, eating and drinking should not be
allowed in the patient care area. Have your office manager or other staff member
thoroughly document your compliance. If you operate a multiple-office practice, each office
must keep separate records.

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127

Blood Borne Pathogens
All employees have the right to know and understand the circumstances surrounding
exposure. Universal precautions should be used to prevent contact with blood or other
potentially infectious material. All body fluid shall be considered potentially infectious if
differentiation of contaminated versus non-contaminated is impossible. Each employer
should ensure that a copy of the Exposure Control Plan is accessible to all employees. The
Exposure Control Plan should be reviewed and updated manually to reflect new and
modified procedures. An employer who has an employee with an occupational exposure
must prepare an exposure determination. An exposure determination includes a list of job
classifications, task, and procedures in which the exposure occurred. Work Practice
Controls (i.e. hand washing, proper disposal of contaminated needles and sharps,
labeled/color-coded objects, etc.) are used to eliminate and minimize employee exposure

Health Care Standards
These requirements, which specifically target the well-being of you and your staff, include
the following:

Medical waste disposal: While the EPA governs disposal of medical waste from the
facility, OSHA governs its handling inside the building. Both OSHA and the EPA enforce the
same basic regulations concerning medical waste, with some subtle variations. For
example, some practices sterilize their medical waste and place it in the regular garbage.
While the EPA allows this with some types of medical waste, OSHA mandates that this step
must not place employees at greater risk either from contracting disease, or from injury due
to increased exposure to autoclaves and the chemicals used to clean them.

You most likely store used needles in a sharps container placed in a safe location. But
under OSHA Guidelines, you also must implement written procedures for the safe handling
of used needles. OSHA also requires podiatrists to adopt its universal precautions to protect
employees from blood borne pathogens and bodily fluids. This includes offering
vaccinations and providing protective clothing (i.e. gowns, gloves, eyewear, etc.) to avoid
possible exposure.

Employee vaccinations: OSHA requires you to offer staff members the Hepatitis B
vaccination. If a staffer declines, make sure you get a signed statement to that effect from
the employee and keep the document on file.

Learning to handle chemicals properly: OSHAs Hazard Communication Standard
requires you to undergo a hazardous chemical handling training program, maintain safety
data sheets, and properly label chemicals for use.

Administering medical care: You must also be prepared to administer medical care if an
employee is injured on the job. First-aid kits are only required if the podiatrists practice is
located more than fifteen miles from the nearest hospital. Turning from the legal to the
practical, however, every practice should have a least one staff member who is trained in
administering first aid.

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Eye protection: Safety eyewear is required by all practices that carry laser equipment.
OSHA requires you to also keep eyewash on hand if employees are exposed to corrosive
chemicals or blood borne pathogens.

Physical considerations: Oxygen and gas tanks must be properly chained down or
secured by another method. Exits must be clearly marked. Having fire extinguishers on
hand is a basic rule of thumb, but it is not enough for OSHA. They must be readily available,
and staff members must be trained on how to use them. Also, posters spelling out OSHA
regulations must be prominently displayed in the employee area.

Record keeping: This is a hot topic. The regulations require you to keep a former
employees medical records for five years after that staffers termination date, unless he or
she was employed for less than a year and receives the records. All other records must be
stored for 30 years beyond the reported event. This time frame is the subject of much
protest from the American Medical Association and from other affected industries. Still,
there is no indication that the 30-year rule will be changed anytime soon.

Concerning employee complaints, OSHRC officials are quite aware that disgruntled former
employees lodge many of the complaints against businesses. Although OSHA mandates
that all alleged violations be investigated, the scope of these inquiries is limited if the
complaint appears to have been filed for harassment purposes. To guard against such a
needless case, keep all administrative files out of your employees reach. If a staffer must
for some reason see his or her file, take precautions to insure confidentiality.

The Unknown
Because regulations are constantly being developed and changed, it is difficult to predict
how OSHAs standards will affect podiatry in the future. For the time being, here are some
general observations:
1. More and more research links the wearing of latex gloves to health effects ranging
from a simple dermatitis to more serious medical consequences. The reason is that
latex is made from more than 200 different proteins, some of which trigger serious
reactions. What is more, health care professionals have increased their use of latex
gloves dramatically in recent years to shield themselves against exposure to the HIV
virus, Hepatitis B&C and tuberculosis. As a result, look for OSHA to mandate the use
of non-latex gloves under latex gloves in the coming years.
2. Airborne nail dust and smoke plumage from cautery also will be addressed within the
next ten years. Podiatrists should now get ready to address this concern.

Simple Steps Toward Compliance
You dont need to take a crash course in public safety, or to spend both day and night
scouring your practice for potential hazards, to satisfy OSHA requirements. Just follow
these simple steps:

1. Develop and maintain an OSHA manual with policies and procedures.
2. Attend seminars as your schedule permits. Dont deputize your office manager or
podiatric assistant, because any fine assessed to your practice will still come out of
your pocket.
3. Know where your OSHA records are kept. Often podiatrists who delegate the OSHA
record keeping detail to their office manager dont think of asking this simple
question. What if that staffer who is the only person in your practice who can locate
the records, suddenly quits? You dont have time to look in a thousand places if, for
whatever reasons, OSHRC suddenly asks you to produce documentation.
129

129
4. Maintain membership in the APMA and other professional associations and societies.
Aside from being a great source of updated information, they employ lobbyists to
address the issues that confront your profession.
5. Read OSHA handbooks. Many are available and they are easy to read.
6. Maintain regular contact with OSHRC. If you are unsure about an OSHA regulation,
just ask. Dont worry that the question might seem too obvious, or that your inquiry
will raise a red flag against your practice.
7. Know where material safety data sheets are located and have them readily available.

For more information regarding regulations and compliance contact:

The American Podiatric Medical Association
800-275-2762
www.apma.org

The Occupational Safety and Health Administration
800-321-6742
www.osha.gov

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Electronic Medical Records

Electronic Medical Records (EMR) are a good way to save money by decreasing
documentation costs, keep reliable records, and to meet the Health Insurance Portability
and Accountability Act (HIPPA) standards. Other advantages to going electronic include:
access to patient information and the ability to share information with other health care
providers, to make your office more efficient, and to improve care for your patients.

With an increased focus on patient privacy and security under HIPPA, patient information
must be kept under strict confidence. Electronic records must fit under the HIPPA standards
and protect personally identifiable health information (PHI). When searching for medical
software, always check to see if HIPPA standards are met.

When choosing an EMR system, there are a few decisions you have to make:

1) Decide what you expect the system to do for you.
x Do you want to incorporate the front office and scheduling?
x Do you expect billing software to be included?
x Do you just need an electronic record?
x Do you want dictation included?
2) Why you want EMR?
x Do you feel comfortable with computer use?
x Is the system user friendly?
x Will this decrease costs and increase efficiency after the staff is trained on the
system?
3) Are you going to run the system on individual computers or inter-office networks, or an
application service provider (ASP)?
x ASPs let the practice rent software from vendors and to access networks from
outside locations with networking and security managed by the ASP provider but the
disadvantage is the data isnt solely under your control.
4) Is the system HIPPA compliant?
5) Is the system secure?
6) What is the data backup system?
7) Can you upgrade in the future if needed?
8) Can more than one user access the system at the same time?
9) How is the data structured? Can you find patient data easily and quickly?
10) Determine whether the transcription system should be included or not in the EMR
system.
x Does the transcription system work for you?
x Do you want interaction with the EMR?

EMR systems are standard in health care today. Educate yourself in the benefits and decide
whether you plan to use them in your office.

References: Reeves, CS. Managing the Medical Practice, 2
nd
edition. American Medical
Association, 2003.
www.elmr-electronic-medical-records-emr.com
www.physiciansnews.com

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E-Prescribing

Medicare started a new financial incentive program to encourage physicians to adopt
electronic prescribing systems. Incentive payments are available now for physicians who
meet the requirements of the program. The initiative is part of Medicare's broader efforts to
accelerate the adoption of health information technology (IT) and the establishment of a
healthcare system based on value.

According to the Institute of Medicine (IOM), more than 1.5 million Americans are injured
each year by drug errors. Medicare believes e-prescribing can help deliver safer, more
efficient care to patients.

In 2008, APMA surveyed members and vendors on their use of electronic health records
(EHR) and electronic medical records (EMR). Survey results indicated that electronic
prescription writing is included in 83 percent of the EHR/EMR systems used by respondents.

Beginning in 2010, for four years Medicare will provide incentive payments to eligible
professionals (this includes podiatric physicians) who are successful e-prescribers. Eligible
professionals will receive a 2 percent incentive payment in 2009 and 2010; a 1 percent
incentive payment in 2011 and 2012; and a one half percent incentive payment in 2013.

Beginning in 2012, eligible professionals who are not successful e-prescribers will receive a
reduction in payment. Eligible professionals may be exempted from the reduction in
payment, on a case-by-case basis; if it is determined that compliance with requirement for
being a successful prescriber would result in significant hardship.

To participate in e-prescribing, eligible professionals must use a qualified e-prescribing
system. A qualified e-prescribing system or program is able to perform the following tasks:
x Generate a complete active medication list using electronic data received from
applicable pharmacies and pharmacy benefit managers (PBM), if available.
x Allow eligible professionals to select medications, print prescriptions, transmit
prescriptions electronically, and conduct all alerts. Alerts include automated prompts
that offer information on the drug being prescribed and warn the prescriber of
possible undesirable or unsafe situations, such as potentially inappropriate dose or
route of administration of the drug, drug-drug interactions, allergy concerns, or
warnings/cautions.
x Provide information on lower-cost, therapeutically appropriate alternatives, if any.
Beginning 2010, a system that can receive tiered formulary information, if available,
from the PBM would satisfy this requirement.
x Provide information on formulary or tiered formulary medications, patient eligibility,
and authorization requirements received electronically from the patient's drug plan
(if available).
x Meet the Part D specifications for messaging began on April 2010. For more
information about the new Part D requirements, please see www.regulations.gov and
search for "Part D prescribing."
To read more about Medicare's electronic prescribing program, see the Health and Human
Services Fact Sheet at www.hhs.gov/news/facts/eprescribing.html. For more information on
APMA's EHR/EMR study, visit www.apma.org/EMEHRinformation.
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APMA Coding Resource Center and Medicare Resources

The APMA Coding Resource Center
APMAs Coding Resource Center, is a fully-integrated online coding and reimbursement
procedure which includes:

The 2011 foot, ankle, leg-relevant CPT codes and guidelines;
The 2011 ICD-9-CM code "Quick List" (complete ICD-9 Volume 1, 2 listings);
The 2011 foot, ankle, leg-relevant HCPCS Level II codes;
Current foot, ankle, leg-relevant Medicare National Correct Coding Initiative (CCI) edits;
CPT RVUs, Medicare assistant surgeon code designations, and Medicare global period
designations;
Individual state Local Coverage Determination (LCD) links for foot, ankle, leg-relevant
procedures/treatments;
DME references and coverage guidelines and links;
APMA Coding article archive (searchable);
Medicare references and citations, including E/M coding and documentation guidelines;
and much more.

APMA Coding Resource Center paid subscriptions are available to APMA members. For more
information visit www.APMACodingRC.org.

Medicare Resources
The Centers for Medicare and Medicaid Services (CMS) has announced the scheduled
release of modifications to the Healthcare Common Procedure Coding System (HCPCS) code
set. These changes have been posted to the HCPCS Web site
http://www.cms.hhs.gov/HCPCSReleaseCodeSets/ANHCPCS.

All changes were effective January 1, 2010, unless otherwise indicated in the effective date
column.
The Centers for Medicare & Medicaid Services (CMS) is also offering a Tool Kit for the 2008
Physician Quality Reporting Initiative (PQRI) that is designed to assist eligible
professionals DPMs are eligiblewith successful reporting. The Tool Kit consists of some
existing educational resources plus new measure-specific worksheets to walk the user step-
by-step through reporting for each measure. To access the Tool Kit, visit
http://www.cms.hhs.gov/PQRI, and scroll down to the PQRI Tool Kit tab. The page serves
as a Read This First Guide to the resources that are available to download. The Tool Kit
consists of the following:

1. 2008 PQRI Physician Quality Measures
2. 2008 Coding for Quality Handbook
3. 2008 Code Master
4. MLN Matters Article 5640 - Coding & Reporting Principles
5. Data Collection Worksheets

According to CMS, The Tool Kit will be expanded as new educational resources become
available.
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Also available is a Medicare Physician Guide: A Resource for Residents, Practicing
Physicians, and Other Health Care Professionals, 9
th
edition, electronic version revised
October 2009, is available in downloadable format on the Medical Learning Network (MLN)
publication page at www.cms.hhs.gov on the Centers for Medicare & Medicaid web site.

The Guide was prepared as a tool to assist providers and is not intended to grant rights or
impose obligations. It is a general summary that explains certain aspects of the Medicare
program, but is not a legal document. The official Medicare program provisions are
contained in the relevant laws, regulations and rulings. The Medical Physician Guide
provides necessary information including an introduction to the Medicare program, how to
become a Medicare provider or supplier, Medicare reimbursement, payment policies,
evaluation and management as well as a valuable reference section.

CMS Signature Requirements

In April 2010, the Center of Medicare and Medicaid Services (CMS) introduced new rules on
signatures designed to reduce the CERT (Comprehensive Error Rate Test) errors found in
medical record reviews. The CMS CERT report stated that violators risk auditor rejection of
claims and demands for repayments. In its latest error rate report, CMS' CERT review of
signatures on medical records revealed that the error rate more than doubled to 7.8 percent
in 2009. To help providers, CMS has detailed new rules on signatures.

Eight suggestions for providers to meet signature requirements on medical records include:

Provide a legible full signature
Provide a legible first initial and last name.
Write an illegible signature over a typed or printed name.
Write an illegible signature on letterhead with information indicating the identity of the
signer.
Use an illegible signature accompanied by a signature log or attestation statement.
Write initials over a typed or printed name.
Write initials not over a typed or printed name, but accompanied by a signature log or
attestation.
Neglect to sign a portion of a handwritten note, but other entries on the same page in the
same handwriting are signed.

Medical records-including physician orders and prescriptions-without valid signatures will be
rejected by CERT auditors, and the claim will be denied for lack of medical necessity.

It should be noted that signature requirements written in national and local coverage
determinations (NCDs and LCDs) trump CMS's signature requirements. For example,
signatures on plans of care must be signed before those services are rendered.

CMS acknowledges that there are existing policies that don't require signatures. For
example, orders for clinical diagnostic tests are not required to be signed. Medical
documentation, such as a progress note, can support the order. However, the note must
have a valid signature.

California School of Podiatric Medicine

The Samuel Merritt University
Board of Regents, administration, faculty
and staff wishes to extend congratulations
to the graduates of the
Class of 2011

The California School of Podiatric Medicine (CSPM) is committed to providing
excellent education and training of podiatric physicians, quality health care,
meaningful community service, and innovative research.
IV.
Practice Options,
Management
and Resources
Aliated Foot and
Ankle Center
Alison DeWaters, DPM
Hal Ornstein, DPM
Howell, NJ
Best of luck in your career.
You have chosen a wonderful
profession.
Advanced Foot Care, LLP
Ira Kraus, DPM
Fort Oglethrope, GA
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Practice Options and Management

Introduction
The option of solo practice is less likely for the graduating podiatric physician than in
previous years. The increasing cost of podiatric medical education and the debt incurred by
students make it difficult but not impossible for the new practitioner to follow this path.
This chapter presents some alternatives to traditional solo practice, how to locate available
positions, and how to evaluate their costs.

The APMA commissioned a work force study to explore the decrease in applications to
podiatric medical schools in the late 1990s that resulted in the decline in the number of
podiatric physicians per capita in the US. A summary of the study, Projections for the
Supply of and Demand for Podiatric Physicians in the United States, 2005 to 2030, was
published in the Journal of The American Podiatric Medical Association (July/August 2008)
and concludes that the growing supply-demand gap revealed important challenges for the
podiatric medical profession to overcome during the next couple of decades.

The study has important practice considerations such as projections, population aging and
growth, supply, geographic penetration, salary, and capacity.

You will also want to review the pre-practice preparation checklist in Chapter III.

Practice Options (See Figure 1)

Solo Practice
This is becoming exceedingly rare due to the difficulty of obtaining appropriate
finances. The biggest advantage is autonomy which also happens to be the reason
many choose medicine in the first place. In solo practice, the physician is the boss
and controls all aspects of the business. However, along with autonomy comes
liability. All investments, expenses, and losses are incurred solely by the physician.

Associateship Leading to Full Ownership
This is commonly referred to as a buy-out. One physician wishes to leave or retire
from a practice while another wishes to enter the practice with the intention to own.
This may or may not require a large initial investment. An alternative is to work
off a down-payment by accepting a reduced salary for a specific duration of time.
Additional payments in the form of one payment (lump sum) or multiple payments
(installments) may be required at the time of the actual take-over. The advantage
of this arrangement is the new practitioner receives some guidance until eventually
becoming owner of a solo practice. The new physician/owner can then change any
aspect of the practice to his/her specifications. Disadvantages of this arrangement,
other than those associated with any solo practice, include lack of growth potential.
It is therefore crucial to fully evaluate the growth potential of a practice prior to any
purchase agreements. One must also consider the patient population. An
associateship prior to full ownership allows both patients and the new physician to
acclimate. While some patients may be lost in the transition, others will be gained.

Associateship Leading to Partnership
This option is appealing to many who are uninterested in solo practice. Partnership
allows for shared liabilities within the business. To be successful, however, partners
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must share similar values and philosophies. If personalities conflict, it is likely that
business choices will be difficult. Serious consideration should be given to entering a
contract where one partner will own the controlling interest thus maintaining greater
power in any decision-making process. Finally, there must be potential for growth
income. This ensures that one partner will not work twice as hard and still receive
only 50% of the revenue. These provisions are routinely included but may vary from
contract to contract.

Associateship
This agreement is for a set amount of time, often 2-5 years, and does not require
any monetary investment in the business aspect of the practice. An associate can be
equated to an employee, although a good contract will include provisions for
bonuses. For example, if an associate earns more than a specified amount, he/she is
entitled to a percentage of that extra income. While this option may be beneficial to
a new practitioner with no long-term plans, five years may be a very long time to
grow financially and professionally.

Figure 1: Comparison of Practice Options

Autonomy Large
investmen
t
Instant
Income
Leads to
Ownership
Liability
risks +
costs
Benefits
(Health
etc.)
Solo
Practice

YES YES NO YES SOLO You Pay
Associate
to
Ownership

YES,
eventually
At some
point
YES, but
lesser
amount
YES Shared,
then solo
MAYBE
Associate
to Partner

NO - will
have some
SOME -
depends
on
contract
YES Only part Shared Usually
paid while
associate
Associate
only

NO NO YES NO NONE Usually
paid
Group
Practice

SOME Depends
on group
Depends
on group
Part
Shares in
group
SHARED Usually
group
pays
Employee

NO NO YES NO NONE Paid

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Group Practice
Group Practice is becoming more common in the modern profession. Groups may be
strictly podiatric physicians or multidisciplinary. Multidisciplinary group practice can
afford the new practitioner the benefits of cost-sharing on rent, utilities, supplies,
and staff. In addition, an instant referral base is available. Participation in a
multidisciplinary group offers slightly more in that there is little or no competition for
patients as well as instant access to other fields of medical expertise. The
disadvantage to group practice is that there are more people involved and thus more
potential conflicts in decision-making. The initial investment and profit-sharing
varies widely depending on the group arrangements. There may be great financial
independence for each practitioner or there may be group profit-sharing. It has
been suggested in medical practice management literature that some solo
practitioners have found it advisable to form groups with other like-minded
individuals. Keith Borglum, a senior consultant with Professional Management and
Marketing, Santa Rosa, CA shares his view that two is a team, three is a crowd, and
four is often a split decision. Five, however, fosters good office dynamics.
Regardless of the final number of partners, the take-home message is that group
practice and solo aspirations may very well find a lucrative common ground,
depending largely on the flexibility of the participants.

Employee
Not everyone wants to deal with the headaches and risks of running their own
business. There is another option and that is to practice as an employee. Many
corporations, hospitals and HMO's are hiring their own podiatric physicians. They are
salaried, have paid vacations and benefits. This produces the instant income many
new practitioners need and requires no initial investment. The disadvantage to being
an employee is that you will have little or no say in how the corporation is run and
may have little opportunity for growth. Unless profit sharing or incentives are
offered, you will not improve your income much by working hard. Because you get
paid the same no matter how hard you work or dont work, this might actually be
viewed by some as a benefit. But be aware of the corporation and the patient load. If
there are many patients to see, you might end up working very hard without
additional financial compensation.

Finding Opportunities

Location
This may be one of the most important factors in deciding in what type of situation
you want to practice. If you want to go back to your hometown in rural Kentucky, for
example, you may have no option but to practice solo if there is no one else there, or
maybe buy out the retiring local podiatrist who convinced you to go into this
profession in the first place. On the other hand, if you want to practice in Manhattan,
you may have to go into a group just to afford the rent. It is important to decide first
where you want to live. If a particular city isn't really important but you want a
lifestyle that includes skiing, or scuba diving use that to guide you. What looks like a
really great opportunity may not be such if you are unhappy in that location,
especially if it is for a lifetime.

Also, beware of people telling you not to go to a certain area because it is
oversaturated. That may not be completely true, so evaluate each area yourself.
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Even in a heavily saturated area, if you have something special to offer, the patients
will come. It may, however, be tougher to make a good living than if you are the
only podiatrist in town.

American Podiatric Medical Association (APMA)
The APMA can help you locate physicians who want to sell their practice and/or hire
associates through classified ads in the APMA News. APMA continually updates and
seeks new information for new practitioners looking for positions. State associations
may also have classified advertising.

Residency Programs
Many practice options come from contacts made during your residency. Residency
directors can be particularly helpful. You may also connect with physicians practicing
out of the same hospital who are looking for an associate or partner.

School and Alumni
Your school can help you locate opportunities. Physicians selling their practices will
often contact the school's graduate placement director. Faculty is another great
resource as they may know of colleagues seeking an associate or wanting to sell. If
you have a good relationship with a faculty member, ask for help in locating a
position or getting in contact with someone who might be able to assist you. Also,
check with the Alumni Affairs Office at your school to see if there are alumni
practicing in the area you want to live.

Hospitals/Local Physicians
If you have a specific city in mind, contact the local hospital to see if they are in
need of your services. In an underserved area, you may get help opening a clinic in
or near the hospital. Contact local physicians in the town and ask them if they are
looking for an associate or partner. Your persistence might prove to them your
commitment to the area.

Evaluating Contracts

Advice
The most important thing to remember when looking at a contract offer is to seek
advice before signing anything. Have a lawyer review the contract and an accountant
make sure all the numbers add up. It may also be helpful to have a practicing
podiatrist review it as well. Have someone you know who has either been an
associate or has employed associates review the offer with you; perhaps a faculty
member from your school or your residency director can help. Do not negotiate a
contract with a joint attorney. If the other party is paying the lawyer, you know
which side will be favored. Protect your interests by having your own attorney! Even
if the contract sounds simple, and especially if it sounds too good to be true, hire
your own lawyer. You are a doctor and not a lawyer.

Income and Profits
Perhaps one of the biggest mistakes a new practitioner can make is underestimating
his/her own worth. After being a student and resident for so long, it is hard for a new
practitioner to estimate his or her own value. This is compounded by the increasing
debt of education and the fear of impending loan repayments. Remember the
attitude that "something is better than nothing" is not always true. Don't accept the
first offer if it sounds too low or has unfavorable conditions simply because you are
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excited to have any offer. Dont panic if the right offer doesn't come right away. You
can always seek further loan deferments or take a position with a shorter term
contract.

The amount you will be paid will vary depending on your situation and that of the
practice. Will you be offered straight salary; commission based percent salary
and/or a bonus? You may be asked what you need to cover your expenses and then
will be paid some amount above that. Have this information worked out beforehand
so you won't be caught taking less than you need to pay your bills. This is where an
accountant comes in handy.

Additional Benefits
Evaluate the contract for additional benefits such as paid malpractice insurance,
health benefits, CME reimbursement, cell/pager costs, national and local membership
dues, license and/DEA fees, vacation time, profit sharing or retirement plans to
name a few. Equate these to a monetary value when evaluating your contract. If
the pay is just okay but the contract offers great fringe benefits, it may be far better
than more money but no extras, all of which you will have to pay for.

Term of Contract
As an associate, a short term contract is better. Avoid contracts longer than 2-3
years. If you are happy after that time, you can re-negotiate. It is very difficult to
get out of a contract once you have entered into it. After a few years of practice and
some more experience, your goals and philosophy of practice may change. If you are
buying out a practice, try to keep the same time frame so you will not become
discouraged waiting for the practice to become yours.

Non-Competitive Clauses
Many contracts have a non-competitive clause included to protect the original
practitioner. A non-competitive clause means that if you should leave the practice for
any reason, you cannot practice in the local area for a certain number of years. The
actual specifics of the size of area (i.e. 10-15 mile radius from existing practice) and
number of years will vary with each contract. Watch out for this in your contract if
you have plans to open up your own practice in the same area after completing an
associateship.

A Bad Deal?
What if after taking all precautions you still get into a bad deal? Much depends on
your contract so before you sign, ascertain if there are provisions for a partner or
associate wanting to leave. A properly written contract should not have a loophole
but a lawyer may be able to help you negotiate dissolution of the contract. You may
be able to sell your interests in the contract to the other party. If there is no way
out, you may have to endure. Hopefully, you did not sign a long term contract.

Sample contracts
See Section: Establishing and Buying a Practice

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Opening a Podiatry Practice

Many practitioners master the art of medicine yet fail to master the economics of their own
medical practice. In fact, few physicians are aware of the basic economics of their
profession. Understanding practice management and medical economics is critical to a
successful practice. As Horace Cotton, a certified professional business consultant, puts it,
"Management, know- how, skilled help, and modern tools are prerequisites for building a
modern private practice. Without the above, the hottest of the hotshots is apt to end up in
the wrong town, the wrong office, with the wrong help, wrong equipment, charging wrong
fees and wondering why all the ink is red." As a new practitioner, you can avoid the
mistakes that may lead you and your practice down the wrong pathway. The following
pages will help introduce you to the secrets of successful practice management.

Forward
This information is organized to guide you through the stages of establishing a practice. It
progresses from choosing a location to presenting yourself to the community as a
professional: organized, staffed and equipped to provide definitive podiatric care.

The emphasis of the article is on locating trades, professionals, and materials. From the
beginning, you must understand that YOU, not someone you hire, are responsible for each
decision, each light switch, each sink, each chair, and that each will be purchased with your
money.

Consultants and employees can be a great asset, but remember that they are not
podiatrists. Do not hesitate to call on experienced members of your OWN profession for that
advice --- they have been in your shoes and will help all that they can.

Ultimately the practice is yours. The successful practitioner draws on his/her own
experience, training, advice from colleagues, local trades, suppliers, and other professions.

I. Office Selection and Location
The first major consideration for the new practitioner is office location. Rule number
one: go where you are needed! Your practice is a business. Before any businessman
establishes his business he first performs a market analysis.

Choose a state or area where you would like to practice. Be sure that the cultural,
recreational and social structure of the community is one where you and your family
will be happy. Remember, that once established, it is very difficult to move from the
area and expect the majority of your patients to follow you.

Select an area that you think will be permanent, where there is room to expand if
necessary and where you can become a part of the medical community. After
narrowing your office location choices to several areas, you need to perform two
tasks: l) collect necessary paperwork and 2) visit the areas. To collect the
necessary paperwork you should contact your national and state organizations and
request statistical information on the areas of interest (current number of podiatrists
in the area, growth of the community, prepaid health plans). The greater the number
of patients that are controlled by such programs as HMOs, PPOs, etc., the fewer the
patients available to the new practitioner. Additionally, you can look through the
APMA News for want ads of interest to you.
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Of course, there may be external pressures from family and friends to establish
yourself in their city. This pressure may be welcome, and the close family ties may
be important enough that you will weigh this heavily in your decision. Remember, it
is your decision and multiple factors play a role in the final analysis.

Do not be afraid to open your practice in an area where other podiatrists are already
practicing. If the patient population is there, you will all make a good living. You may
determine that your methods of practice are different than your podiatric colleagues
and you will attract a different type of patient.

Always visit the areas you are considering. During your visit to the areas you have
selected, stop at the:

County Medical Society which will have information regarding the local
professional climate, e.g. whether or not there are large group practices in the area.

Local Health Department - A public health officer usually is cognizant of the area's
health strengths and weaknesses. He can provide you with accurate local statistics.
For example, he will be able to brief you on the local welfare services and possibly
age demographics.

Local Hospitals - Write or phone the hospital administrator prior to your visit to the
hospital(s) and set up an appointment. Ask for a tour of the facility, procedures and
qualifications necessary to obtain hospital privileges. Ask him for information
regarding local medical groups and third party coverage in the area.

City Hall - A city hall visit will provide you with information regarding public schools,
police, fire, water, transportation, and property taxes.

Chamber of Commerce - The Chamber of Commerce will provide you with data on
the town's trade pattern, its industry and prospects for the future. Information on
churches, libraries, clubs, shopping facilities and recreational activities is also
available.

A Real Estate Office and a visit with a broker will give you the opportunity to
question an expert about the surrounding areas, neighborhoods, zoning, rentals, and
market values.

Local Podiatric and Non-Podiatric Physicians may contribute valuable
information. Another quote from Horace Cotton, author of Medical Practice
Management, "Realize picking the wrong place to practice isn't just bad
management, it's also bad medicine because somewhere there are lots of patients
who really need your services."

II. Office Site
After deciding on a city or town, you must choose an office site. Start by locating a
law firm which has partners specializing in real estate, corporate, and litigation law.
A reputable law firm may fill all of your other future legal needs and provide
important business and political links. Such connections may help in the selection of

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contractors, accountants and even office help. Although political connections may
seem irrelevant, they often are helpful later in your career.

Obviously a reputable real estate group is invaluable in the selection of an office
location. They have a solid awareness of a specific location's personality, its growth
potential, and specifics about the population in that particular sector of town. Be sure
to utilize their expertise in this phase of setting up shop.

A podiatry office should have easy access with an absolute minimum of steps. A
second floor walk-up location should be the last resort. If space is not available on
the first floor of the building that you are considering, an elevator is a necessity.
Remember that many of your patients will be unable to climb stairs.

Whether you decide to build, purchase, or rent an existing medical office, make sure
you have enough rooms. A doctor's office should have a patient waiting area to
comfortably seat patients and their guests. Many successful practitioners entertain
the idea of one room, one job. For instance, have a business office, a mini surgery
room, several examining rooms and a consultation room. Don't forget to set up a
space for your nursing staff. Hall corridors should be four to five feet wide to allow
two way traffic and wheel chair access.

For some practitioners, a home-office location works well and may provide major tax
advantages. The home-office lifestyle does not suit every family. Talk to other
practitioners, with different styles of offices and practices and then decide.

Renovation costs are often much higher than expected so a written estimate from
two or more general contractors is a must before finalizing purchase or lease. In a
lease arrangement, the renovation costs should be covered in the contract, i.e. who
pays for what, restrictions regarding contractors, building codes, etc. In a purchase,
the lawyer will help in determining these things.

III. Financing
A commercial bank is your best bet for financing. Be prepared when approaching a
bank finance officer for a loan by having a basic knowledge of the current interest
rates, bank financing policies and other such financial matters. A referral to the loan
officer by the bank manager, your lawyer or accountant, another doctor or a
business associate is the best way to handle arranging an appointment.

Currently, banks are not as willing to lend money to fledgling doctors as they have
been in the past. They must see you as a good investment. Therefore, be prepared
to use your credentials. Podiatrists are successful practitioners and can be a valuable
asset to the community, and an important part of the health delivery team.
Podiatrists are employers, consumers, and investors. When you walk into the bank,
have the self-confidence to project that image. Make the bank representatives aware
of your potential; you are going to become a responsible customer.

A bank will invariably make the loan you're seeking if you provide acceptable
collateral. You may want to ask for alternative low-grade collateral such as title to an
automobile under two years old, etc.

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You should consult with more than one bank since different banks may have different
options and different levels of willingness to invest in you. You may receive multiple
offers but select the best one to meet your needs. A good corporate lawyer may
suggest a bank that has full services and a reputation of dealing with professionals.
The financial and other agreement terms are vital when opening a new office. This
can be "make or break time." Therefore, this is a critical time to consider advice,
opinions, and consultations before signing on the dotted line. All decisions are
ultimately your responsibility; however, it is best to use the experience and expertise
of other professionals.

IV. Accounting Firm
An accounting firm should have a good community reputation with a number of
clients in health professions to be familiar with the specific needs and requirements
of the health care professional.

Experienced accounting firms should have the capability to prepare a draft budget of
your requirements. The first budget item should be accounting fees with their
charges fully explained. Items such as rent, renovation costs, equipment, auto
expenses, insurance, telephone, property taxes, utilities, and office salaries can be
estimated very closely with the firms experience. Several recurring expenditures
such as office and medical supplies will have to be estimated along with your own
salary or other expenses that only you can determine. Make sure all the personal
needs of your family are accounted for in your budget, including your student loans.

V. Summation for Banking Purposes
When putting together a financial package for presentation to a bank, a simple
outline can serve as a useful guide. A well prepared, well documented, and detailed
portfolio can be your best ammunition in securing a loan or line of credit to establish
your practice and assure that you will be able to meet your financial obligations. The
following is an example.

Part I: Cover Sheet

Purpose of Loan: These funds are required to set up a private practice in podiatric
medicine and surgery. The office address is: ________. These funds will be used to
decorate, furnish, purchase necessary equipment, keep office overhead current, and provide
living expenses for a family of (x) until the practice supports a profit.

Part II: Table of Contents

1. Curriculum vitae
2. Personal financial data (assets, liabilities, and net worth)
3. Itemized estimate of starting up a practice
4. Projected budget
5. Demographics
6. Fee schedule
7. Last two years' tax returns

Of course, each item within the table of contents should have its corresponding section
within the body of the portfolio. The way the presentation is drafted is a matter of
personal preference, but these are the basic items necessary for a bank to consider
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before granting a loan or line of credit. In addition, requesting an appointment with a
senior vice president in commercial lending may be an advantage. This individual can
consider your proposal and make a decision without consulting a loan committee. Come
prepared with the details a bank needs to approve the loan and your chances for
success improve dramatically.

For more information, see the Establishing and Buying a Practice section of this Guide.

VI. Constructing an Office
Once you have established the amount of funds needed to build, equip and
supply your office, it is time to turn to your lawyer, accountant and banker for
referrals to competent builders, general contractors and architects.

In some cases, your construction crew will be predetermined by the building
management. Once you have completed the plans/layout of your office with the
architect or space planner, it is important to visit the space periodically to check
on progress and determine that the work is being completed to your
specifications. Do not hesitate to contact management if you are unsatisfied with
any details. This will be your office for many years to come -- get it right the first
time.

VII. Architects
The traditional role for an architect/space planner is to prepare drawings with
specifications as to materials and construction techniques. Architects are
responsible for inspecting the site at various stages of construction. The architect
provides guidance for the general contractor. When the work is completed, the
architect gives the client a written review and certification that the work has
been satisfactorily completed; the specifications have been followed and the
premises are ready for occupancy. The fee for these services is an agreement
which is typically a fixed percentage of the contract price. For an agreed lower
price, architects may only do the drawings and list the specifications.

In some regions, there has been a trend in the last few years for architects to act
as contract managers. In this arrangement, the architect will do the drawings
and specifications and call for lenders either on a general contract basis or on a
trade (i.e., plumber, electrician, carpenter, dry wall, etc.) basis, with the final
selection being made by you. The architect then follows the traditional role of
supervisor.

VIII. Design Corporation
Professional office planning consultants can offer a variety of planning services. They
will have drawings prepared either by an architect or by their own drafting staff.
They will do detailed interior design specifications and generally supply all materials,
furnishings and fixtures including wallpapers, carpet, paint, cabinets, furniture, office
machines and, in some cases, even your professional supplies and equipment.

Their scope is quite broad and they often act as either contract managers or as
general contractors. These firms always work on a pre-set contract price, with any
additional work or supplies being priced individually. As professionals, they also can
offer discounted pricing, a wider variety and a higher quality of interior decorating
materials and furnishings.

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If the firm is well established, with a good reputation, it is very often the most
satisfactory method of preparing an office. These designers can work economically if
they perceive that you are diligently supervising all expenditures. On the other hand,
if you insist on only the best and most expensive materials, they will tend to consider
their services in the same light and final contract prices can be unreasonably high.
Some or all of these costs may be picked up by the building management but these
determinations must be made prior to the contract.

IX. General Contractors
The role of the general contractor is to act as the project manager and
troubleshooter between you and the individual building trades.

Contractors usually act in one of two methods. The contractor will estimate the work
to be completed and prepare an agreement usually adding a managing fee to handle
supervising and coordinating the trades and building supplies.

A general contractor may also call for bids from each trade and then review them
with you and then make certain that the work completed is to the specification and
satisfaction of the architect.

The general contractor is paid at specified stages of completed work. The fee may be
negotiated or simply a 10-15% addition to each trade and supply item.

X. Self-Contracting
Without a doubt, this is the most exciting and involved method of having your own
construction project completed. The drawings are prepared with specifications by you
and/or your architect. This concludes the architect's responsibility.

From here on you act as your own general contractor. You are responsible for
supervising each trade, assuring that workers show up on time, complete all work,
and adhere to specifications. You will also be responsible for making certain that
each trade's work is inspected and approved by municipal officials.

Real savings can be made with this method of contracting, but you must be sure that
you have enough background in the building business to deal with each trade and
sufficient composure to keep calm when there is time lost, supplies stolen or broken
or when difficulties with building inspectors occur.

You will eventually have the satisfaction of seeing your own ideas realized, but you
must also be prepared to live with each problem that occurs. The person who can
handle self-contracting is rare.

XI. In-House Contractor
Many office buildings are owned or managed by general contracting companies.
These companies often hire their own tradesmen for maintenance purposes as
mentioned earlier. They can justify their retention by having tradesmen do
renovations in these buildings from time to time.

For this reason, they may insist that all work done in their building be done by their
own trades people. They may even require that the office layout be prepared by
their office, and that fixtures and furnishings be similar to the other office suites.
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This often applies to floor coverings, window treatments, wall coverings and
plumbing fixtures.

In this situation, there may be an allowance in the lease for some building
renovations, with any extra charges being incorporated into the lease. These extra
charges will need to become part of your loan request to the bank.

XII. Podiatric Medical Planners
Many podiatric medical supply houses offer free planning services. In return for your
patronage, they will prepare drawings with some general specifications at no cost.
With square footage at the price it is today, be sure that a plan, regardless of who
prepares it, understands the per square foot cost of space and uses space efficient

Remember that the supplier may specify as many of his supplies as possible
including cabinetry, fixtures, and equipment. This is only reasonable, and calls upon
your discretion to separate the need from the greed.

XIII. General Comments
The most common problem that occurs among those not in the contracting business
is lack of understanding of building codes. Insist that your designer or architect spell
out that the drawings are in compliance with the building code and that any
renovations or adjustments required to meet specifications are the designer's
responsibility.

Make sure that major electrical and all plumbing installations are grouped for
efficiency and cost savings. If you can arrange to have all of your plumbing along
one wall of the office for example, you will save a significant amount of money on
plumbing charges.

Finally, remember that almost no building project goes smoothly no matter how
carefully you plan or select your contractors or trades people. Be realistic and be
persistent, but be patient.

XIV. Office Time Management
Time is money is a well-known adage that can work for you or against you
depending on your time management skills. At an annual meeting of the American
Academy of Family Physicians, Keith Borglum, a senior consultant in professional
management and marketing, had the following advice with respect to time
management:

Find ways to minimize staff costs: For every $1 your office brings in, staff costs eat
up 23-25 cents. If you're regularly paying employees for overtime, your financial
picture is probably even worse. Regular overtime is an indication of a problem,
Borglum says. Do nurses stay late because they feel guilty leaving before the
receptionist? Fix it.

Schedule visits efficiently: Give your scheduler guidelines about the number of
minutes typically required for seeing a particular type of patient. That way, you can
schedule an efficient mix of shorter and longer patient visits and avoid bottlenecks
that will slow down the receptionist and the billing staff. According to Borglum, by
spending one hour a week meeting with your office staff to work out problems and
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two minutes a day reviewing your schedule to plan your time, you could increase
your profitability by $500-$1000 per month.

Delegate anything that doesnt require your medical degree: Example: Are you
spending $200 an hour to open your own office mail?

Use your accountant less: By moving your accounting in-house and making it part of
your accounts payable system, you'll be able to save $500-$1000 a year, he said.
Use a financial software package to handle your own profit and loss statements and
reserving your accountant's time for preparing your taxes and providing advice will
help your bottom line.

Extend your office hours: Consider opening your office earlier and closing it later.
You'll win points with working patients, and simultaneously, you'll be able to add
more patients. This does not necessarily mean, however, that doctors and staff must
correspondingly lengthen their workday. Borglum suggests creating a split-shift
schedule, where some physicians and employees work from 7:00 a.m. to 1:00 p.m.
and other work from 1:00 p.m. to 7:00 p.m. Alternate different days, if you prefer.
This makes for great marketing," he says. Just make sure you don't put a night
person on the morning shift and vice-versa. Taking the little extra time it requires to
determine good teamwork groups and personal productivity profiles will prove most
profitable in this scenario.

XV. Office Supplies and Equipment
Unless there is a dramatic difference in price, it is advantageous to purchase general
office equipment and supplies from a general office supplier in your city. Again, rely
on your contacts and check with several other people to direct you to the best
supplier in your area.

One respected supplier can usually give you good pricing when handling the whole
office. Moreover, this supplier will establish an individual account so that you will not
need to use petty cash for sundry items that may be needed on a weekly basis. The
key again in purchasing supplies is to order only what you can use in the near future.

A band-and-tag approach can make reordering of supplies more efficient. This
simple technique involves putting rubber bands around each set of items in your
supply closet, along with tags describing the supplies and how many are in the set.
Once one set has been used, its tag should be placed in a central envelope. At the
end of the month, tags can be tallied, and reorders can be placed at one time.

XVI. Computers
All new practitioners should have computers. The technology and programming of
these units has changed so rapidly in the past five years that they are now a viable,
affordable and necessary concept for each podiatry office. Obviously the initial
investment can be quite high, but the benefits to your practice will soon have the
computer paying for itself. Some computer capabilities to consider include: billing
patients; following up delinquent accounts; preparing health insurance claim forms;
maintaining a running analysis of office productivity (where profits and losses are
generated); patient distributions, including age, sex, diagnosis, and treatment;
scheduling; payroll; tax returns; and bookkeeping.

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The variety of work done by computers is limited by the programming, its functions,
and the selection of the proper hardware. There is now a number of software
companies with packages specifically designed for podiatrists. These companies
attend most of the large podiatry conventions and are more than willing to discuss
your needs at that time. Careful research in advance will allow you to choose the
best system for your office now and in the future.

XVII. Podiatry Equipment and Supplies
A good podiatry supply house can fill all of your equipment and supply needs.
Moreover, with an initial set up order, these houses will often offer a discount, and
establish credit on future orders. Choose your suppliers and then maintain a good
relationship with them to assure good credit, service and delivery.

When choosing your supplier, meet with several different representatives before
making your final decision. You may determine that price is solely what you are
looking for, or you may decide that a good service record and pleasant working
relationship with the company is more important. A good question to ask is, "Does
the supplier's representative want me to succeed or just make a sale? Do they
support the APMA and the profession?

To reduce overhead costs initially, buying good used equipment or supplies can be a
very wise approach. Don't be afraid to contact other practitioners and explore this
possibility with them. It can be a good deal for both parties but always remember to
check expiration dates.

XVIII. Advertising
Many years ago, advertising by members of the medical community was considered
unprofessional. Today, most podiatrists do some advertising and many derive the
majority of their patients from ads.

There are numerous ways in which to advertise in a professional manner. First,
determine what is consistent in your community. You may choose to have a general
advertising campaign, consisting of a combination of yellow pages, newspaper and
other types of promotional materials. Before doing so, check to be sure you are on
solid legal and ethical grounds. Any advertising program that is not professionally
prepared, ethical and in good taste will not generate a good return, and may cause
tension between you and the other area practitioners.

XIX. Marketing
In Is There Life After Residency? Hal Ornstein, DPM, outlined a clear difference
between marketing and advertising. As a new associate, you need to be marketing
savvy. Marketing does not equal advertising. Marketing is meeting local doctors or
public speaking, and advertising is a newspaper ad. Marketing can further be broken
down into external and internal marketing. External is that which promotes the
practice outside the office and internal is how the patients are handled and marketed
to within the office, such as with patient welcome letters. Coupling these skills with
use of the proper media can be a real boost to a new practitioner. The techniques
learned and the contacts made will help throughout your practice life.

The easiest and most accessible medium is through presentations to local clubs and
groups. Community, civic and service clubs are regularly searching for guests to
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speak at their meetings. You may not see immediate results from this type of
marketing, but the benefits can be great later in your practice.

These groups want a presentation that will give them direct, useful tips and insights.
Keep the talk simple, short and pointed. If you are using audio or visual aids have
them complement, not supplant your address. Always see that printed material is
handed out to reinforce the presentation.

Pamphlets are available for use as handouts from the APMA or you can prepare a few
pointers on your letterhead. Of greater importance is that you make yourself
available to those in attendance, staying for a reasonable period of time to answer
personal questions.

Notice of your presentation can be treated as a news item in your community paper
if you prepare a summary sheet and send or deliver it to the paper one week before
the event. All significant points should be mentioned in 300-800 words in a form the
newspaper can print directly. If possible, have pictures sent to the paper after the
presentation; papers are often looking for visuals.

An important reminder about marketing: remember the largest supplier of patients
may be HMOs and PPOs so market to them as well.

XX. Using the Media
The media (including the local newspapers, magazines, community handouts, radio
and television) are commercial enterprises competing for readership, listeners, and
viewers. The material they present must be colorful, controversial, or both.

If you submit articles to the local paper, be aware that most editors will change and
edit submitted material at their discretion, which is within their right. Many
professionals hesitate to approach the media for fear of being misquoted. On the
other hand, if you learn the technique of giving the media what they want through
an exciting presentation, you can have no better friends in the community.

Live radio conversation shows are another good means of exposure for a new
practitioner. If you know your subject well and have a good delivery, you may find
this type of media exposure to your liking.

In summation, make yourself available to the public. To do this professionally it
takes preparation and education on communications. Approach these situations
seriously and positively -- they will help your practice and can be a lot of fun.

XXI. Referrals
Referrals are an important aspect of any podiatric practice. Following are
some effective rules to abide by if you'd like to attract referrals:

1. Report back to the practitioner promptly after seeing the patients.
2. Return patients to their referring doctor.
3. Make personal contact with potential referring doctors.
4. Offer the referring doctor an active role.
5. Build your reputation ethically.

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XXII. Staff
A new solo practice office will only require one full or part-time employee. He/she
must function as host, chair-side assistant, typist, bookkeeper, and housekeeper.
Any future staff you require should be able to fill any of these posts, even though
their individual duties may become more specialized day by day. It is important to
note that your office manager should be a highly qualified and experienced
individual.

Patients are most impressed on the first visits. The office and its staff, including you,
should have a neat and clean appearance and exude friendliness, with some
professional reserve. The staff you hire must be able to project that image.
Assistant duties can be learned on the job. Suggested criteria:

1. First and foremost, motivation and enthusiasm.
2. A demonstrated ability to type, and to transcribe dictation from a dictating
machine (if applicable).
3. A neat and clean appearance with a friendly and professional demeanor.
4. Character references which mention honesty, promptness, and good work ethic.
5. Intelligence, and manual dexterity displayed during the interview, that in your
judgment will allow the assistant to learn and execute duties satisfactorily.
During the interview allow sufficient time to conduct the interview, generally
15-30 minutes. If, while interviewing, you discover the applicant will not do,
cut the interview off politely. You should have a mental picture of the type of
employee you are looking for in detail. Be sure to include questions relating
to education/work history background. Open-ended questions should be
utilized. After you have chosen a candidate, it is wise to offer the new
employee a trial period of ninety days.

Your staff should become enthusiastic about podiatry, and the services that are
rendered. They deserve to be treated with respect. The salary paid should be in line
with community standards, their abilities, and enthusiasm. Don't be cheap, but do
keep in mind that studies have shown that money is not the only factor in employee
satisfaction. The working conditions and environment on the job actually have been
found to be more significant to employee dedication and satisfaction than a slightly
higher salary.

Extra benefits are best avoided because individual preferences and family situations
make them difficult to administer, and of little value to one staff member, while of
real value to another. An exception is a flexible pension plan. Every employee
appreciates a portable, flexible retirement fund.

XXIII. Informed Consent
Ultimately, the most important relationship in one's practice is that between the
doctor and the patient. Podiatry is a field with both medical and surgical applications
in daily practice. The tenets of informed consent are crucial in establishing a
relationship based on trust and understanding.

The following list may be helpful in evaluating if you are upholding your end of that
communication:

The Physician's Checklist for Informed Consent

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1. Make sure the patient understands the nature of his or her medical condition.
2. Make sure the patient understands the nature of the proposed treatment or
procedure.
3. Make sure the patient understands the possible alternative treatments or
procedures.
4. Make sure the patient understands the medically significant risks of the
proposed and alternative treatments.
5. Make sure the patient understands the chances of success or failure of the
proposed and alternative treatments.
6. Disclose the identity of the chief surgeon when he or she is other than the
attending physician.
7. Disclose any risk of death or serious harm.
8. Disclose the peculiar risks associated with a specific treatment or procedure.
9. Disclose risks to a greater extent when the proposed treatment or procedure
is experimental, new, novel, high-risk, capable of altering sexual capacity or
fertility, or purely cosmetic in nature.
10. Disclose the intent to perform procedures incidental to the principle
procedure.
11. Make the disclosure yourself and do not ask or expect the nurses or assistant
to handle this for you.
12. Follow the rule the greater the risk the less the chance of therapeutic
benefit, and the more you should explain to the patient to obtain his or her
consent.
13. Act as if you or your family were on the receiving end of the treatment
procedure.
14. Record your disclosures and the consent in a permanent way, either by a
detailed writing in the medical or hospital records of what you disclosed or by
using an explanatory written consent form.
15. Make sure you fill in the blanks where the operative procedure or proposed
treatment should be indicated.
16. Don't say you are going to do a routine operation, as none is routine.
17. Don't inform the patient that the treatment procedure is simple.
18. Don't tell the patient that no complications will occur because complications
may occur.
19. Don't expect to obtain informed consent by merely answering the patient's
questions because he/she won't necessarily ask you the right questions.
20. Don't expect a patient's signature on a consent form that was given to him or
her just moments before the procedure.

XXIV. Insurance
Before opening your practice, be sure you are properly protected by several forms of
insurance. The following is a checklist of the different types of insurance that should be
purchased: commercial, tenants, homeowner's, auto, malpractice liability, personal health
insurance, income disability, office overhead, and life insurance.

For more information, see the Insurance section of this Guide.

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Motivating Your Staff

The success of any medical practice begins and ends with the staff. A well-motivated,
excited and enthusiastic staff is the key to a successful marketing program.

Your best presentation at a community service meeting can be an absolute failure if the
receptionist shoves the sign-in sheet at a new patient and then slams the opaque window in
his or her face. All your best efforts of establishing good physician referrals could be wasted
if you have rude staff who takes the attitude that they are doing referred patients a favor by
giving them appointments in four weeks instead of sometime that very week.

There are two different attitudes your employees can have toward their jobs. The first
attitude: your employees don't like to work and avoid work whenever possible. They have
no ambition. The only thing they look forward to is payday and vacations. The second
attitude: your employees enjoy their work and find themselves seeking more responsibility.
They are self-starters and need only to be pointed in the right direction to get the work
done. Obviously, you would like to have employees who matched the second description
working in your medical practice. Unfortunately, many medical practices and doctor's
offices are run with employees who match the first attitude description. These employees
generally have limited job descriptions, are over-managed, are given little real
responsibility, and have limited incentive to accomplish tasks above and beyond their job
description.

Abraham Maslow identified the "hierarchy of needs" and theorized that human beings have
basic physiologic needs that they are driven to satisfy such as hunger, thirst, air to breath,
shelter, and sex, and after these basic needs are met, certain social needs become
motivating factors for behavior. These social needs identified by Maslow are acceptance,
recognition, status, and prestige. He feels that by directing your attention as an employer to
these social needs, you can build a team of employees who are motivated to do ordinary
jobs in an extraordinary fashion.

Before you can focus on the individual social needs of your employees, you must have a
staff comprised of employees who are capable of being enthusiastically motivated. As an
employer, you must be able to identify these types of people in the initial interview. It is
possible to stimulate some individuals to a higher level of motivation, but often it is very
hard to maintain this higher level of motivation if it is unnatural. Therefore, this capacity for
change on one's motivational attitude must be available within the individual to allow for
success.

A medical office can indeed be a conductive environment for stimulating employee
enthusiasm and motivation. However, before this effect can occur among the staff there
must be a few criteria presently existing in the office. First, there must be a good rapport
between the employer and the staff. Second, there should be a friendly atmosphere in the
office. Lastly, a respectful attitude regarding the services rendered must be present. It is
very difficult to encourage enthusiastic motivation in your staff if there is an unfriendly or
tense atmosphere in your office. It is also important to note that if you are able to maintain
good rapport between the practitioner and the staff members, you will keep the lines of
communication wide open which invites personal motivation.

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Employees must also feel as if they are an integral part of the larger health care unit and be
proud of their association with it. This type of feeling is generally developed with conceptual
agreements and respect between the employer and employee. Without this feeling,
motivation can only be occasional outbursts, but with this feeling, an outpouring of
motivation can result.

Another method of producing and sustaining enthusiastic motivation in your office is by goal
setting. The practitioner can encourage the staff members to set short and long term goals.
These goals can either be focused on their individual work or could pertain to the medial
office as a whole. Either way, you are establishing an atmosphere that encourages personal
pride and personal achievement therefore, establishing personal enthusiasm and motivation
in the medical office.

Practice management is actually a conglomerate of principles and guidelines that help the
practitioner maximize both office efficiency and productivity. The staff is the primary
vehicle through which all these principles and guidelines are executed. This task of practice
management is much easier if you are dealing with staff members who are enthusiastic and
motivated in their daily work.

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How to Connect with a New Patient in Sixty Seconds

According to many studies, we all determine whether we like or have confidence in
someone within seconds of the first meeting. Your patients level of acceptance is often set
with signals you send immediately upon entering the treatment or consultation room. This
first sixty seconds with a new patient is your opportunity to lay the foundation for your
successful relationship during the entire course of treatment.

Have you taken a critical look at what you say or do the first sixty seconds you are
with a new patient? Too often we have our eyes looking into the patient chart as we quickly
get into questions about the chief complaints without forming that all-so-important
personal bond. Although you are providing medical services, your comments, body
language and demeanor those first sixty seconds set a generic stage common to all
delivering a service to customers.

You are constantly confronting patients who are not like you; they all have different
strengths and weaknesses. The mistake we make is that we too often think everyone thinks
and reacts like us and they clearly do not. They present with a high degree of anxiety and a
fear of the unknown even though they appear calm and in control. Most patients, due to
their previous experiences and prejudices, come to our offices with a preconceived notion
that the doctor may lack a degree of personal skills. This first sixty seconds is your
opportunity to break through this barrier and gain this patients trust by showing them that
you are a caring human first and then a doctor!

First and foremost, when first speaking with patients focus on eye contact, the most
fundamental skill taught but often not put into practice. If you have a hard time doing this,
practice for a week, noticing the eye color of everyone you come in contact with. Eye
contact is important throughout the entire patient visit, especially when you are presenting
your treatment plan. Focus on controlling distractions that can cause your eyes to sway or
head to turn, losing important eye contact.

Smiles Count

The universal language spoken in any land is a smile. Its amazing how barriers are
broken down when you enter the treatment room with a simple smile and what can be
called a connecting comment such as How are you today? Its nice to have you in our
office. I am Dr. Sullivan. This is so much more powerful than the canned, Hi, I am Dr.
Sullivan, what can I do for you today?

You must believe you are on stage and everything is being evaluated in hyper speed
leading to a bottom-line conclusion about your personality, body language, personal hygiene
and caring. This is your opportunity to let your personality shine and break the stereotype
of the cold doctor. A funny thing happens when you smile: others do too.

Be a Good Listener

Some brief thoughts about the remainder of your patient visit beyond these first
sixty seconds. Listening is one of the most important skills that will result in winning your
patients trust and earning you high marks. Listen to others and they will listen to you; you
will get to know more with improved accuracy and you will gain their confidence. Letting
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others finish before you begin to speak delivers the message that you are sincerely
listening. Acknowledge that you are actively listening with a small nod of your head, an
occasional yes or uh-um and occasionally repeating back what your patient just told you
in short form. Once again listen with your eyes by focusing on that all-so-important eye
contact.

It is quite the challenge to change how we behave and react. But if there is just one
thing you take from this article, spend a portion of that first sixty seconds to speak with
your new patient as if you were meeting him/her at a party. Speak about anything other
than why they are in your office, such as how they heard of the office, what they do for a
living, what a beautiful day it is, something you have in common...just anything but their
feet! I challenge you to focus on these first sixty seconds for the next two weeks and see
how you spend this time with your patient. Have your assistants observe you and provide
feedback. Getting on the same wavelength with your patients for those sixty seconds is a
skill that any doctor or medical assistant can learn. Do not underestimate the power of sixty
seconds.

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Give Patients a Pound of Gold in a One-Ounce Bag

The Physicians Role

The perception of time spent with your patient is related to your energy directed toward
them. Their psychological and medical needs can be fulfilled in a short time with simple
techniques. This starts with their perception and expectations. Their expectations can be
exceeded by making their perceptions reality. Much of this information shows common
courtesies our parents taught us as children, which are frequently lost in adulthood.

This section will discuss the role of the physician in delivering your patient a pound of gold
in a one-ounce bag. Each and every patient encounter should begin with eye contact and a
friendly smile as you cross the doorway into the room. Follow this with a handshake even if
youve seen the patient a hundred times This delivers a clear message of warmth and caring
and helps to reduce the fear factor patients often experience. This opens their minds and
ears to what you then tell them about their conditions. These simple skills say to the
patient that you are friendly and relate to them at the same level, not on the ivory tower
many physicians seat themselves.

As you begin to speak with them place both hands on their feet. Studies have consistently
proven that human touch portrays compassion. Begin your conversation with a question
relating to their overall well being such as how have you been? This may lead to an
extended conversation so be sure to control the conversation by switching to how their
podiatric problem is doing, i.e. so, hows the heel feeling? At this point LET THEM SPEAK
and get it all out. The typical patient will do this fairly quickly. However, if you interrupt
them early on in the encounter to move the visit along they will feel you are rushing. If
they speak their peace, the rest is yours to control.

Patients comprehend significantly better with their eyes than ears. Each treatment room
should have:

x a poster sized picture of common foot and ankle conditions (professionally framed)
which can be purchased from Krames and Anatomical Chart Company
x foot bones
x 8 x 11 tear-off pads with conditions and anatomical outlines to write on
x a large board with erasable marker available through podiatric supply companies

By the patient visualizing their condition, their questions are reduced and they leave with a
better understanding. Before discussing the patients condition, have them read a brochure
outlining their condition, etiology and treatments. Information on the patients related
condition will reduce the amount of questions and will further reduce anxiety. The patient
may also review this information at home with their spouse, neighbors, and friends.

Time spent with the patient will be reduced if you take control of the visit. This sounds
obvious but too often, the patient leads the visit. The patient is in the office because you
are the expert. Deliver your treatment plan with confidence and the patient will more likely
accept and follow your recommendations. Stay away from statements such as you may
benefit from and I think this may work Emphasize the importance of the treatment by
using phrases like, this is critical for you to have relief or this will make a significant
difference in how youre feeling, and our goal is to get you better as quickly as possible so
you can return to your normal activities and reduce the chance of surgery.

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A key factor of your patients perception of time spent with them is your energy delivered
also known as charisma. Of all the skills taught and learned, this is the most difficult to
acquire yet it delivers the strongest message of compassion, caring and making the patient
feel that you value their relationship. This perceived energy creates the Halo Effect that
creates a good feeling on the patient that they are part of your successful practice and does
not require much of your time to feel fulfilled. Consider each time you walk through the
door of a treatment room the spotlight goes on and you are on stage. Mary Kay Ash,
founder of Mary Kay Cosmetics, has said to make believe everyone has a sign around their
neck that says, Make me feel important.

There is a direct relationship to patient waiting time and the amount of time a patient
expects to spend with the physician. There is no magic pill to lessen waiting time however,
after analyzing many different practices, one of the most common problems among all of
them is lack of productivity due to inefficiency. Many offices do not effectively utilize and
empower their back office staff to serve in the role of physician assistants. An assistant
should serve as an extension of the doctor with the ability to effectively answer questions,
perform functions, and free up the doctors time to move into the next room. In chemistry,
we learned that the rate limiting factor, which equates to the physician, is the primary
provider of care. If there are four treatment rooms, the most important two rooms are the
one the doctor is in and the next one they are going into. This topic can be an article in
itself but in a nutshell, each doctor in the practice should have a second back- office
assistant in the room during the visit to act as an extension of the doctor, and ready to
work directly with the patient (within the assistants scope), after the doctor leaves to room.
Done correctly, there is not loss of quality of care or delivery of customer service. In most
cases quality of both are improved. Moreover, be sure to train them through observation,
seminars, reading and membership in the American Society of Podiatric Medical Assistants
(www.aspma.org).

If you will be writing a letter to their primary care physician, let the patient know this is
being done to keep their physician informed about their health. The patient greatly
appreciates this and it shows you are thorough. A common compliant with patients is that
the doctor did not answer all their questions. This issue can simply be addressed by asking
this open-ended question at the end of each encounter What other questions do you
have? Ask this while looking at them in the eyes with your hands lying on their feet. Be
sure to thank their patient for coming in to your office. They appreciate being recognized
and valued as lending to the success of your practice. A comment like enjoy the rest of the
day or looking forward to seeing you next time ends the visit on a positive note.

The Assistants Role

When an assistant looks at their job as a career, and genuinely enjoys what they do, they
actually become self-motivated and want to contribute to the overall success of their
practice in much the same way as a physician does. They take ownership and pride in
making it successful. Under the tutelage and support of a very nurturing doctor, the
assistant may participate in building mutual practice philosophies and goals: they are not
satisfied with just sitting back and waiting for things to happen, but have a desire to pitch
in, take action, and MAKE them occur. The synergistic attitude that develops as a result of
this energized doctor/assistant team ultimately ends up benefiting not just each other but
in a bigger, better way their patients. And dont be fooledyour patients know the
difference between those offices that have it and those that merely pretend!

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An assistant can contribute to making the patient feel important in three major areas.
Think of these as the 1-2-3 winning combination or (to steal a common sport
terminology) the hat trick combination. They are:

1. Using their TIME more functionally to fine-tune the efficacy and productivity of the
office
2. Contributing to raise the standards of QUALITY OF PATIENT CARE through the
advancement of their own skills and proficiency
3. Creating a POSITIVE ENVIRONMENT by personally focusing on and involving the
patient

Breaking this winning formula down will show how each one can maximize your practice
operations.

TIME: When we talk about using time more functionally, should the greater emphasis be
placed on your (time) or your assistants? The answer is both. With respect to patient care,
you can utilize your assistants time in such a way that allows you the necessary freedom to
generate more revenue elsewhere. For example, consider delegating some of the habitual
typical organizational duties that you might normally do, such as explaining (and many
times explaining again) pre-op, post-op, surgical expectations, at home re-dressings,
orthotic instructions, prescriptions, hospital test preparations, (e.g. MRIs, bone scans,
Doppler studies, lab tests) and even directions to the hospital. Having a well-trained
assistant right in the room with you can help to develop this concept to an even greater
level. For example, you no longer have to call your assistant into the room to verbally
delegate these tasks. Their mere presence automatically begins the process. They hear
you tell your patient, Mrs. Jones, I am going to start you on an oral antifungal which will
help your nail condition. Immediately, the assistant begins writing the prescription as well
as a lab order for blood work, discusses with the patient a convenient facility to have the lab
work done, makes the appointment for them (if necessary), gives them instructions and
directions to the facility, helps them with their shoes and socks (if they require assistance)
and reschedules another office appointment for follow-up. NOTHING further needs to be
said by the doctor communication has already begun and work is in progress.

This is just one scenario. There are many other conditions that when precipitated by the
doctors conversation with the patient, can spur certain customized protocol. Take as
another example - heel spurs. This particular conversation might stimulate the assistants
preparation of an injection (which could be prepared in advance, dated and labeled for
added efficiency), X-rays, physical therapy, preparation and/or application of bandages
(including the care of the bandage), review and demonstration of exercises, writing and
explaining an anti-inflammatory prescription, recommendation of a water-resistant bandage
cover (purchased at your office) and rescheduling the next appointment. Once this becomes
the new routine, and the doctor is confident that the assistant can competently handle the
situation, (s) he will feel comfortable enough to leave the treatment room and move on to
the next patient, knowing that the patient will not feel slighted in any way by their
departure. For this one patient, the time saved for the doctor has been substantial.
Imagine how the duplication of the same procedure can affect the flow and revenue of an
entire day?

CONTRIBUTING TO QUALITY PATIENT CARE: A motivated assistant can go beyond the duties
described above, adding another whole dimension of professionalism to your practice.
Involving them in direct (non-invasive) patient care will instill in that assistant positive
feelings of growth, self-worth and accountability all vital to job satisfaction. Anyone that
has had difficulty retaining staff knows that staff turnover is a very costly endeavor.
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Trusting them to carry out certain agreed-upon clinical responsibilities (such as castings,
bandaging, removing of sutures, etc.) can be as equally rewarding to them personally as it
can be to the practice reputation. Additionally, it will ignite patient satisfaction, respect and
trust, making the patient more acceptable of allowing the assistant to perform activities that
would normally be performed by the doctor. Depending on their level of proficiency,
training, and eagerness to learn, the assistant can be phased-in to the actual hands-on care
of the patient with great success. Under your direct guidance and through regular in-
service training workshops, they can be taught to deliver exceptional assistance above
and beyond the monotonous housekeeping obligations of merely cleaning whirlpools and
filling drawers.

CREATING A POSITIVE ENVIRONMENT:
Patient satisfaction undoubtedly starts with a good attitude and loyalty. The attitude you
want your office to project, must start at the top. If you choose to have a good attitude
each day, the assistants are bound to catch it and before you know it, the trickle-down
effect soon touches the patient. In this kind of environment, giving becomes almost as
natural as breathing and from it, patient satisfaction increases substantially.

Once again, we will focus on the assistants role and how they can help improve patient
relations through effective communications. A familiar passage written by Robert Fulghum
comes to mind called, All I Really Know I Learned in Kindergarten. Summarized, Mr.
Fulghum reminds us that our lives should constantly mirror the basic common courtesies we
were taught as a child among them, to share, be fair, be nice, dont steal, say youre
sorry, dont hurt others, maintain personal hygiene and have fun. Unfortunately, many
times they are lost and forgotten; however, if we make this universal philosophy the active,
driving force of our overall practice goals, we would not limit ourselves to just providing
good patient care, rather we could deliver SUPERIOR customer service and with very little
effort!!

The patient-assistant relationship only has to start with a phone call from a frightened
patient. From that point, the assistants ability to satisfactorily answer their questions,
soothe their concerns, and make every attempt to pleasantly accommodate their schedule,
will guide them another step towards the door. When entering the office door, the assistant
is the first to greet them with a warm, welcoming smile, a personal hello and an extended
hand a concentrated effort to emotionally touch the patient and expand upon their
already positive first impression. A heartwarming story, a lending ear, a comforting
shoulder, and genuine humor allow the relationship to mature. Combine all these elements
with proficiency and professionalism and G O A L! Your assistant has just helped in
scoring a HAT TRICK in healthcare management for your practice.

In conclusion, mining for and delivering that pound of gold requires teamwork. It has long
been known that a team approach to healthcare maximizes patient satisfaction and patient
outcomes. Each member of a team has their special abilities. Know your staff well.
Determine each members strengths and weakness as well as likes and dislikes. If all staff is
empowered to deliver those essential ingredients those patients come to need and desire, a
tremendous amount of synergy will ensue. Some beneficial results include:

i Higher team satisfaction
i Lower employee turnover
i Higher patient satisfaction
i Higher patient compliance
i Lower litigation
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i Improved outcomes
i Improved community standing
i Lower operating costs
i Higher profitability
i Lower organizational stress

The practice of medicine is as much an art as it is a science. Physicians and their staff must
strive to understand patients from a psychological as well as physical standpoint. Never
underestimate the power of patient perceptions. During patient encounters, you must
eliminate all negativity from your conscious mind such as office issues, personal problems,
and dislike of the patient. The art of a golden touch is often only delivered by an
enlightened hand. And finally, remember that they may forget what you said, but they will
never forget how you made them feel!

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Customer Service and Continuous Quality Improvement to Enhance
Patient Care
Not too long ago, a colleague asked me what the term practice management meant to
me. I suppose that this term can take on many definitions. My answer started out by
stating what practice management did not mean to me. While improved revenue or
increased profit is the outcome of good practice management, it is not what defines it.
Practice management should have a patient-focused definition. Customer service
enhancement, improved efficiency, patient satisfaction, staff management, business
administration skills, and cost containment are all integral parts of my definition of practice
management. Even the latter few, while sounding more financially-focused than patient-
focused, have an indirect, yet profound effect on patient care. All, of course, lead to the
outcome of improved profits.
All processes within a medical office have an impact on customer service. Direct patient
contact is not required. Telephone personnel, billing and collection personnel, outside
vendors, labs, as well as hospital and surgical facilities all have an impact on your perceived
quality.
10 PRACTICAL PRACTICE MANAGEMENT TIPS
9 Recognize that every employee in your practice has an impact on
customer service and the patients perception of your quality.
9 When addressing problems, frame your reply in a positive
manner rather than a negative one. Rather than saying its
against our office policy to do that, reframe it with an alternative
by saying what I will do is
9 Use the patients name when communicating with them.
9 Remain calm. Respond rather than react. The former is based on
intellect while the later, on emotion.
9 Keep your internal problems internal. Patients have enough
problems of their own!
9 Recognize that you have primary customers (the patient),
secondary customers (the primary care physicians), and tertiary
customers (the insurance company).
9 Educate your patients as much as possible. Occasionally, a lack of
information has an adverse effect on the patients perception of
your quality.
9 Explain all delays.
9 Smile!
9 End all encounters with do you have any other questions and
thank you.
THE ALARMING FACTS:
x Research has demonstrated that a typical satisfied customer will tell 2-3 people
about their experience while a dissatisfied customer tells 9-10!
x It costs six times more to obtain a new customer than it does to satisfy and keep
an existing one!
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An important aspect of good practice management, perhaps as a subset of customer
service, is the concept of Continuous Quality Improvement (C.Q.I). W. Edward Deming was
perhaps the father of C.Q.I. His concepts, while developed and applied to the
manufacturing industry, now permeate many organizations, including healthcare.
Continuous quality improvement is an approach to quality management that focuses on
processes rather than the individual. While there are many well known customer service
techniques that circulate around most management programs, medical offices are in need of
some simple tools to help quantify and develop continuous quality improvement strategies.
IMPORTANT DEFINITIONS WITHIN CQI
Incident: An unusual or undesirable event that disrupts an organization, or is not consistent
with normal patient care. It may involve a significant violation of established policies and
procedures.
Sentinel Event: An unexpected occurrence involving death or serious injury.
Root Cause Analysis: A process that identifies the underlying cause of an incident or sentinel
event designed to prevent a reoccurrence.
Dissatisfiers: A dissatisfier is the absence of 'expected quality'. Customers expect products
to be essentially flawless, and if they are not, they are dissatisfied. Customers usually don't
tell us what their 'expected quality' is because they take for granted that we will provide it.
Examples of dissatisfiers would include custom orthotics that are a poor fit and instruments
that are unclean.
Satisfiers: A satisfier is something that customers want in their products, and usually ask
for. The more we provide a satisfier, the happier customers will be. Examples of satisfiers
are increased office hours, greater after-hour accessibility, and written information
regarding their condition.
Delighters: Delighters are product attributes or features that are pleasant surprises to
customers when they first encounter them. A typical customer reaction to a delighter is to
say to a friend, 'Hey, take a look at this!' The needs that delighters fill are often called
'latent' or 'hidden' needs. An example of a delighter would be a post operative get-well card
or flowers.
These definitions demand a few strategies from practitioners. An incident, by definition, can
never be documented without the existence of written practice policies and procedures. It is
crucial for practices to have an employee manual.
To understand what is important to patients, an annual satisfactory survey should be
performed with results reviewed with your staff and responses planned.
The sometimes exhausting search for the truth is also important. The root cause of a
problem often lies deep to the surface. With the relentless search for why, we may begin
to understand the true cause of a particular problem. As an example, a telephone that
seems to ring busy too often may easily be attributed to its operator. The root cause,
however, may be an insufficient number of incoming telephone lines.
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CORE CONCEPTS OF CQI
9 Quality is defined as meeting and/or exceeding the expectations of our customers.
9 Success is achieved through meeting the needs of those we serve.
9 Most problems are found in processes, not in people. CQI does not seek to blame
people, but rather to improve processes.
9 Unintended variation in processes can lead to unwanted variation in outcomes,
and therefore we should seek to reduce or eliminate unwanted variation.
9 It is possible to achieve continual improvement through small, incremental
changes using a scientific method.
9 Continuous improvement is most effective when it becomes a natural part of the
way everyday work is done.
CORE STEPS FOR CONTINUOUS IMPROVEMENT
9 Form a team that has knowledge of the process needing improvement.
9 Define a clear goal and objective.
9 Understand the needs of the people who are served by the system (our patients).
9 Identify and define the measures of success.
9 Brainstorm potential change strategies for producing improvement.
9 Plan, collect, and use data for facilitating effective decision making.
9 Apply a scientific method to test and refine changes.

The Failure Mode and Effect Analysis (FMEA) is an interesting CQI tool that is already being
employed by many health care facilities. It may be modified and applied to private offices to
assist in a quality improvement program. It is a simple, yet proactive view of potential
events and should become part of our daily normal practice management protocol.

Normally, when a problem arises, we look back to establish a root cause. It would be far
more efficient, however, if we could prevent things from going wrong in the first place. That
is the purpose of the Failure Mode Effect Analysis. It looks at a process and asks what if?

A process is placed under the microscope with the intent of precluding potential problems.
Placing each process step on a graph helps to identify the points of potential failure.

The likelihood of the failure is evaluated:
1= Remote/no known occurrence
2= Uncommon occurrence
3= Occasional occurrence
4= Frequent occurrence
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The severity of the possible failure is categorized:
1= Minor or no impact
2= Moderate impact
3= Major impact
4= Catastrophic, long term impact

The level of risk is then determined by calculating a hazard score (probability of failure x
severity).
Severity
> Probability
v
(4)
Catastrophic
(3)
Major
(2)
Moderate
(1)
Minor
(4) Frequent 16 12 8 4
(3) Occasional 12 9 6 3
(2) Uncommon 8 6 4 2
(1) Remote 4 3 2 1

Attention is placed on the failures with the highest hazard scores (as an example 8 or
above). As a working example of how the FMEA may assist in office quality improvement,
lets consider the process of dictation/transcription. The steps of the process are graphed:
Potential for Failure

1. 1a. Doctor behind on dictation
1b. Doctor forgets to dictate
1c. Dictation incomplete

2. 2a. Transcription lost

3. 3a. Delay at transcription
3b. Incomplete/mistakes in
transcription

4. 4a. Transcription lost

5. 5a. Placed in wrong
5b. Chart missing/delay

6.

Hazard Score: (Hypothetical scores for step 1 only)

SEVERITY PROBABILITY HAZARD SCORE
1a. Doctor behind 2 4 8
1b. Doctor forgets 4 2 8
Patient seen-
note dictated
Tape removed-
sent to transcription
Tape transcribed
Transcription sent to
office
Transcription
placed in chart
Chart filed again
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1c. Incomplete 4 3 12

In this example, all potential failures in this step had a hazard score which warrants further
study. Incomplete dictations demonstrated the highest hazard score (12) and should be
given priority in establishing the root cause and possible solutions.

Once your team identifies the process step needing improvement, another tool may be
employed to facilitate change. Developed by statistician Walter Shewart in the 1920s, The
Shewart Cycle (or PDCA cycle) is a straightforward protocol designed to implement a
change. The cycle consists of Planning, Doing, Checking, and Acting.
Plan: The team brainstorms to develop an improved step. The step
with the highest hazard score is addressed first.
Do: The improved step is implemented.
Check: The revised step is studied to determine its success.
patient satisfactory surveys may be needed.
Act: The revised step, if successfully improved, is maintained. If the
attempt is unsuccessful, returning back to the planning step is warranted.

Another useful and practical quality improvement tool is the S.W.O.T. Analysis: Strengths,
Weaknesses, Opportunities and Threats of your practice. Some question examples:

STRENGTHS

x What are your
advantages?
x What do you
do well?
x What
resources
do you
have?
x What do
others see
as your
strengths?
WEAKNESSES

x What could
you improve?
x What do you
do poorly?
x What should
you avoid?
x What do
others cite as
your
weaknesses?
OPPORTUNITIES

x What possible
opportunities
could arise?
x Are there any
interesting trends?
x Are there any
possible
technology/
procedural
opportunities?
THREATS

x Any
possible
changes in
govern-
ment
policies?
x What is
your
competitor
doing?
x Cash flow
problems?

The SWOT Analysis allows you to visualize both internal (you and your staff) as well as
external (patient satisfactory survey) data. Annual data review data should be followed by
corrective action. Consistent utilization of these simple tools of quality improvement will
greatly enhance your practice. They can be applied to any of the numerous processes that a
podiatric practice consists of. They have a significant effect on patient satisfaction,
efficiency, costs, and yeseven profits!

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How to Step up Assistant Efficiency

Efficiency is finding a new approach, in the most productive way, in the least amount of
time; a concept built by proficiency, organization and innovation. Most times when you give
staff a job to do, unless directed otherwise, they are inclined (sometimes strongly
encouraged) to do it exactly the way they are taught, which by the way may not always be
the most effective. Sticking to this one-way method, while considered workable, closes
off doors of opportunities for change and leads to stagnation on many levels, for the
assistant (personally and professionally) and for the practice. It is only after staff is given
permission to actually take control of their job and own it, that they are motivated to
develop new methods that will not only result in the same outcome (maybe even a better
one) but quicker and with greater satisfaction. Its called job challenge. Self-determination
allows them to become the architect of an all new improved way, through careful re-
organization and innovative strategies. I might suggest that rather than observe efficiency
from the perspective of what can my assistants do to be more productive for me? it
becomes all the more valuable to ask instead what can I do that will give my assistants the
necessary space to allow them to be their most productive?

Whats essential is understanding that everyone has their own unique way of arriving at the
desired outcome with the emphasis not so much on how we arrive there, but that we
ultimately arrive. In my presentations, I try to drive this point home by displaying on the
screen a number of illusions. Each of these visuals can be viewed one of two ways. As in
this illustration below, one person may clearly see a duck at first glance (looking left) while
another may see a rabbit (looking right.) Whos wrong? Neither. Its not a question of
right or wrong - it simply becomes a matter of perspective. So, just as the same
visual can be seen two different ways, so can two people see different ways to arrive at the
a similar outcome.

Its all about empowerment. The efficiency concepts above are not possible if the doctor
does not first put a great deal of trust in their staff or allow them complete ownership in a
project. Managing does not mean looking over their shoulder and telling them how
something should be done. Managing is empowering them to set their own pace and find
their own way. It is important to set goals and desired outcomes for your practice. Then
step back and give your staff the space they need to implement their own innovative ideas.
They want to succeed, for themselves and for the practice. Without the freedom to try new
things, the positive process known as efficiency is stifled. With it, they have an excellent
opportunity to grow and produce in a nurturing environment.

Id like to share with you some ideas that I encourage you to share in turn with your staff.
Maybe they are already doing them with great satisfaction; maybe they will take one of
these ideas and go with it; make it even better. These are only ideas, not solutions. Give
them the opportunity to take them in their own direction, increase their own efficiency and
make them worthwhile realities for your practice.

x Make the time to properly train your assistant to where you can delegate more
hands-on responsibility which in turn will help to free up more quality patient time
for you. Delegating a minute here and a minute there adds up and before you know
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169
it, the possibility of seeing one patient more per hour exists. There are many duties
you can delegate such as reviewing instructions with the patients for a number of
things e.g., prescriptions, pre or post op care, orthotic wear and care, getting
injections, casting for orthotics, how to wear a pneumatic boot, injury care, etc.
Encourage assistants to make suggestions of other areas that they feel they could
help and together discuss the possibilities of making that happen. Keep in mind that
allowing your assistants to participate and contribute in this way not only frees up
more of your time, but also relates to your assistant a feeling of trust while elevating
their professional image to your patients. Its a win-win all the way around.

x Review with assistants the proper way to respond to patient questions, such as Why
do you need to take all this information regarding my medical background? or Why
should I have the doctor make these orthotics for me, when I can get them cheaper
at the sports store down the street? Together, develop a canned response which
will address patient concerns, but make sure it is rehearsed in such a way that the
assistant can deliver the response as naturally as their own name.

x Encourage assistants to develop whatever new forms are necessary to help them
better organize the office. One example might be a form which clearly directs them
through certain processes such as obtaining patient insurance verification or a
surgery check list to verify contacts and make sure everything is ready to go when
the day of surgery arrives.

x Allow assistants to develop their own pattern in which to organize patient charts, so
that everyone knows immediately when opening a chart where to find what. For
example, one side might contain all medical information, while the other side all
billing info. Because patients seem to always be changing their health insurance, we
mark the newest copy of their insurance card with a neon-colored sticky note
folded over one side. When we open the chart, we dont need to flip through all the
sheets to find their card, we all know its the one that sticks out with the neon note
attached to it.

x Have a referenced list of most used prescriptions handy, so that assistants can
write them for you as they hear you discussing treatment plans with the patient.

x Make it a point to have assistants review all patient charts prior to beginning the
day. Stopping to request a lost test result or failure to contact a patient whose
referral is not up to date can severely interrupt patient flow. Knowing what the day
holds (patient-wise) will allow everyone to better plan their day.

x Encourage assistants to ergonomically and effectively re-arrange their office space to
where things are more convenient and comfortable for theme.g., have the things
they use most often, such as the copy machine or the shredder placed in close
proximity to their desk. Arrange things so that they are within easy reach and
always find ways to save steps whenever possible!

x Encourage them to make folders for items that they use on a daily basis; label them
however they wish and place them where they are easily accessible. This keeps
loose paperwork off the desk and organized. I use color coded folders and place
them in a graduated file holder on top of my desk for easy viewing.

170
170
x Save time when a new patient presents to your office by mailing them a registration
form ahead of time to fill out at home. (Weve even incorporated an address label
right into the form itself, so when we fold it up to mail it, the patients name and
address is visible.) Now, in addition to being able to see this patient on time
(instead of waiting for them to fill it out in the reception room), it also allows them to
provide a more concise list of their meds, certain telephone numbers they might not
have with them and it gives the elderly patients the ability to have someone at home
help them fill it out.

x Keep a dated telephone log to record all incoming and outgoing telephone messages.
This also serves as a reminder to document things patients say to you, a reference
for phone numbers not yet recorded and it keeps all messages together, eliminating
the clutter of scattered post-it notes.

Promet
page black and white
p/u 10
cab logo
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171

THE APMA PRIVATE INSURANCE RESOURCE GUIDE

Given the current managed-care environment in which policies of private payers are in a
constant state of flux, dealing with private payers can be as difficult as navigating in open
water. In response to this challenge, the APMA Health Systems Committee (HSC)
developed the Private Insurance Resource Guide (Guide) for APMA members as a compass
for seasoned and new practitioners, to chart the unfamiliar territory. The Guide is available
in electronic format only at: http://www.apma.org/PrivateInsuranceResourceGuide
The Guide provides invaluable practical and easily accessible information for insurance-
related challenges that may arise from the time when a patient sets foot in the office to
when the podiatric physician receives the appropriate reimbursement for care rendered. The
Guide is an exhaustive resource containing practice management information and state
statutes pertinent to the practice of podiatric medicine. Contributors include HSC Committee
members, practice management experts, health law attorneys, and APMA staff.
The Guide is organized with the objective of a practicing podiatric physician in mind: What
should I do when a claim for a covered service is rejected based on medical necessity while
the private insurer persistently delays the processing of the claim? What should I do when
subjected to an unfair discount on reimbursements? The Guide is organized by subject and
should be read in conjunction with the state laws available in the APMA State Reference
Manual (www.apma.org/StateReferenceManual) and other official pronouncements.
Each chapter covers one subject area and provides background information as well as
recommended short and long term solutions. Because numerous factors may affect the
success of a claim, some repetition in the subjects covered among different chapters can be
expected.
Chapter 1 - Private Insurance Internal Claims Appeal - This section includes two
complementary articles. Decoding Coverage Decisions outlines different types of utilization
reviews employed to review medical claims submitted to private insurers. Private Insurance
Appeals provides an algorithm for podiatric physicians to address denied or delayed claims
systematically. The two articles are complementary in that Decoding Coverage Decisions
enables podiatric physicians to identify reasons for claim denials correctly, while Private
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Insurance Appeals enables the physicians to initiate and sufficiently prepare for effective
internal claim appeals. Private Insurance Appeals also discusses the Private Insurance
Advisory Committee (PIAC) process that the APMA, in conjunction with state podiatric
medical associations, has established to resolve members private insurance concerns.
Knowing and utilizing the state-appointed PIAC representative may help in getting access to
the medical director and his or her management team in a more timely fashion. An APMA
PIAC directory also is included in this section. The PowerPoint presentation Appealing
Denied or Modified Claims: Getting Paid for What You Do integrates concepts introduced in
the two earlier articles with other aspects pertinent to a successful medical claim, such as
state utilization review laws (see Chapter 9), correct coding practices, using the Correct
Coding Initiatives (CCI) edits, and other tips.
Chapter 2 - Managed-Care Contracting Can be lengthy and seemingly impossible to
interpret; as a result, many podiatric physicians recoil at the prospect of having to review
and understand them. Although reviewing these contracts is not pleasant, failing to do so
carefully may expose podiatric physicians to significant liabilities. This section includes
articles, a PowerPoint presentation, and sample letters to provide detailed, step-by-step
information on how to protect a practice through contract negotiation.
Chapter 3 Recoupment - Recoupment occurs when private insurance companies
request the repayment of previously paid claims for a variety of reasons. In this section,
attorneys identify different reasons for recoupment. Additionally, it provides a detailed
discussion on the implications of state laws and insurers contractual provisions on different
types of recoupment, timeframes, and procedures. Furthermore, it provides a model
recoupment legislation and a checklist designed to help podiatric physicians and state
podiatric medical associations review the provisions in their provider contracts that may
affect an insurers ability to request the repayment of previously paid claims.
Chapter 4 ERISA - Since its passage, the Employee Retirement Income Security Act of
1974 (ERISA) continues to be the most litigated managed care issue. In addition to ERISAs
preemptive effect on state laws, an employer-sponsored ERISA plan must establish and
maintain reasonable procedures governing the filing of benefit claims, notification of benefit
determinations, and appeal of adverse benefit determinations. Included in this section is a
PowerPoint presentation, a fact sheet published by the U.S. Department of Labor (DOL)
discussing patients rights claims procedures regulation under ERISA, and an advisory
opinion from the DOL regarding claim procedures under ERISA. Additionally, it includes a
discussion on the importance of obtaining a valid ERISA assignment from a patient in order
for the practitioner to defeat unlawful payment denials successfully.
Chapter 5 Antitrust - The purpose of antitrust laws is to constrain certain types of
concerted activities among competitors, which in turn promotes competition and enables
consumers and competitors to have fair market access. This section discusses how
frustrated providers may have more ability to work together than they think when dealing
with managed care organizations without violating federal and state antitrust laws.
Chapter 6 - Economic Credentialing Is the process of determining a physicians
qualifications to participate in a health plan network or [to receive] privilege[s] by a
hospital, based in whole or in part on utilization of health care services and lower cost of
care, without regard to the appropriateness of the care furnished (APMA Position Statement
on Economic Credentialing). In its purest form, economic credentialing measures a
providers performance on the basis of his or her use and utilization of resources, unrelated
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to the quality of care or professional competence. This section provides an overview of when
and how economic credentialing may occur.
Chapter 7 - Silent PPOs - Is any type of arrangement that results in an insurer paying a
physician a discounted fee even though the physician is not a member of the insurers
preferred provider network and does not have a contract directly with the insurer. This
section provides a comprehensive discussion on when and how a podiatric physician may be
subjected to unfair discounts and appropriate steps to avoid them.
Chapter 8 - Third-Party Administrators (TPAs) - Refers to an administrative
organization that processes and pays claims and that may provide other administrative
services on behalf of payers, such as self-insured employers and associations. This section
includes a comprehensive study of TPAs that addresses the unfair practices of TPAs and
other intermediary entities, such as down coding, arbitrary reimbursement changes,
procedure denials, and network participation decisions.
Chapter 9 - State Laws - This section provides summaries of state statutes governing the
practice of podiatric medicine and managed care. The section also includes laws that protect
the right of podiatric physicians to provide healthcare in various settings and the right to
just and prompt reimbursement. The overview of state statutes in this section only
highlights important elements in the statute and is a supplement to the APMA State
Reference Manual, which is a compilation of statutory text.
Chapter 10 - Medicare Advantage Plans - The increasing number and types of Medicare
Advantage plans presents both challenges and opportunities for podiatric physicians. In this
section, Kelli Back, JD, discusses the Medicare Advantage program, including the way that
Medicare Advantage plans are regulated, as well as podiatric physicians rights and
responsibilities with regard to treating members of such plans, either as a participating
provider or an out-of-network provider.
Chapter 11 - Out-of-Network Provider - When a podiatric physician renders care as an
out-of-network provider, that physicians right to payment and obligations are not set forth
clearly in a written agreement, such as that between an in-network provider and the
contracted private insurer. This article outlines strategies and factors to consider when
seeking payment as an out-of-network provider.
Chapter 12 - Sample Letters - Medical offices devote countless hours and human power
to appeal denied claims. A medical offices ability to appeal a denied claim effectively and
obtain a favorable outcome improves the financial well-being of the practice, and allows the
podiatric physician/staff to conserve time and energy to provide healthcare. Included
samples commonly encountered issues with managed care organizations and serve as a
starting point to initiate communication with private insurers.
Chapter 13 - Frequently Asked Questions - In this chapter, the HSC has compiled
scenarios podiatric physicians encountered when dealing with managed care organizations
and proposed strategies that enable podiatric physicians to advocate for their rights to
provide medical services and to receive reimbursement.
In addition to the above-mentioned sections, the Guide includes other reference materials in
the appendix, which includes a managed care glossary and a list of commonly used
acronyms, ERISA statutory and regulatory text, and information on private insurance
companies and state insurance commissioners.

The discipline of learning. The art of caring.

Western University of Health Sciences
College of Podiatric Medicine
309 East Second Street
Pomona, California 91766-1854
909-706-3933
http://prospective.westernu.edu/
V.
Podiatric
Marketing
Aliates in Foot Care
Peter Paicos, DPM
Lieke Lee, DPM
Stoneham, MA
Congratulations and
welcome into the family
of podiatric physicians.
Kathleen Stone, DPM
Glendale, AZ
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Practical Marketing Tips for Practice

As a private practitioner marketing is an integral aspect to your practices success. Group
and multi-specialty practices should also market and advertise. Making a name requires
effort and it needs to be lasting. Marketing can be an effective tool by which you can:

l. Communicate your patient-oriented philosophy to public and referral sources.
2. Create a positive professional image in your community.
3. Help build a strong and growing patient base.

As a starting point, think about your practice objectives. Who is your target patient base:
diabetics, children, athletes, the elderly or all of these? Of course, you want to market in
areas that you are proficient, so now you need to link your objectives with those in your
base. How does the quality of the service given to your patients match their expectations
and needs?

Marketing can help you identify and match your professional objectives, your patients'
objectives, and your referral marketing. Over time, you should gauge your marketing
success. Two strong measures are the number of loyal repeat patients and the number of
satisfied patients and referral physicians who refer their family, friends, and patients to you.

Most practice management consultants suggest that the individual practitioner
begin with a general marketing plan.

1. Where have I been?
2. Where am I?
3. Where do I want to go?
4. How can I get there?

Answer #1: Will help you review not only the history of your practice but also your
professional accomplishments, your education, training, and experience.

Answer #2: Will give you a concrete description of your current patient population, referral
network, and financial health. A patient profile helps identify your patients. The profile
reveals dominant patient characteristics, e.g., age, sex, race, employment/income status,
geographic distribution, referral source, reimbursement source, common diagnoses, and
common surgical/therapeutic procedures. A practice profile can show the worth of your
practice. One method of determining the financial status of your practice is to list your
practice figures for the last two years, i.e., total charges, total receipts, collection ratio,
accounts receivable, overhead costs, total adjustments, and your personal income. The
answers may give you ideas on how you can strengthen and improve your practice.

Answer #3: Will help you develop quantifiable objectives, action plans, timetable, and
budget. A practical objective is specific and measurable, e.g., to increase the number of
new patients seen by one patient per day. Tied to the objective are specific action plans,
e.g., exhibit at a local health fair, perform foot screenings at a hospital's open house,
lecture at a public health forum, write a foot health column or newsletter, and place an
advertisement in the local paper. Before executing any action plan, it is best to outline a
timetable and budget for each plan. You will want to monitor the success of each action
plan. How can you measure the effectiveness of any action plan? You will want to ask a
new patient about a referral source by including a question on the patient's initial
registration form.

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For some action plans, you may wish to create a response action, e.g., offer a
complimentary foot health brochure or newsletter. By creating a response action, you can
track the success of your plan by the numbers of patient responses.

A total commitment to "service excellence" is the key ingredient for a healthy
practice.

Joe Casurella, 3M Health Care Manager of Professional Relations said, "We [3M) realized
that we don't define quality -- our customers do, and second, in a truly competitive market,
quality is the most important competitive strategy an organization can adopt." Studies
show that satisfied patients are your best sources of new patients; unsatisfied patients are
three times as likely to express poor experiences.

Promoting your practice involves both internal and external positive public relations. Tom
Peters, a management consultant, urges the practice of service excellence in all businesses.
Service excellence means a commitment to businesses. Service excellence means a
commitment to delivering the best possible service to the customer. It is a practical
commitment of everyone in the business to "do the best I can, and to strive for excellence
in my work." This should be true of all employees; everyone has a role to play in the entire
patient experience, whether they are at the front desk, or behind the scenes.

How has this concept of service excellence been implemented in American businesses? One
example is the "Managing Total Quality" (MTQ) program of the 3M Company. The MTQ
approach signals the company's commitment to its customers' expectations. A customer is
anyone who receives a service or product from the company's staff. Joe Casurella describes
3M's MTQ as a principled process: The MTQ approach is based on a number of fundamental
beliefs:

1. Quality is a positive strategy for growth. It should be integrated into the
strategic business plan.
2. The commitment to quality must start at the top.
3. Quality must permeate the organizational efforts. Everybody must
participate.
4. Quality is a process, not a program. It is a journey, not a destination.
5. Quality benefits everybody -- customers, employees, community, and
organizations.

How can service excellence be measured? For a practitioner, it can start with the initial
contact. Internal operations play an important role in your public's perception of your
practice. Often it is the intangibles, the personal attention given to the patient, which make
or break a practice. Other ways by which your service excellence can be measured include:

1. The way in which you and your staff communicate with your patients.
2. The ease by which your patients can schedule an appointment.
3. The time that your patients wait to see you.
4. A convenient office location.
5. The appearance of your reception area and office suite.
6. Convenient office hours.
7. The ease of your billing procedures.

You may wish to develop a "Managing Total Quality" program for your practice by involving
your staff in the planning and implementation process. Your patient's description of
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services you render often rest on their perception of you and your staff's availability and
willingness to respond to their needs. Key items to discuss with your staff include:

1. The kinds of services that your patients generally seek.
Provide your staff with a cheat sheet of common procedures, surgeries,
treatment protocols, etc., so they are equipped to answer basic patient
questions.
2. The kinds of services you want to provide to your patients.
Staff should keenly be aware of expertise, and be able to honestly
communicate practice objectives. If a patient request is not consistent with
your practice supply, educate your staff of other podiatrists or specialists that
can handle their needs. Staff should maintain patient relationships with your
office, by encouraging them to follow-up with you for other podiatric needs, if
warranted.
3. How to communicate your commitment to total quality to your
patients and public.
Having canned response to the fundamentals of your practice helps
maintain consistency in your practices message and public perception.
4. How to relate the needs of your patients with your staff's
responsibilities and tasks.
To make patient care more efficient, staff should know what conditions
constitute podiatric emergencies. If a patient needs to be seen immediately,
admitted, or needs a referral, staff should be able to make certain judgment
decisions.
5. How to create positive patient responses.
6. Office appearance.

As your discussions evolve, you may wish to discuss specific areas for improvement. These
may include:

1. Telephone etiquette.
2. Sensitivity to patient relations.
3. Patient scheduling and waiting times.
4. Sensitivity to billing procedures and insurance issues.
5. Staff personal appearance and manner.
6. Office appearance.

The telephone is a critical marketing tool. Warmth and interest in the patient's well-being
can be conveyed over the telephone. Many practice management consultants suggest that
all staff be trained to answer the phone with a smile, a pleasant "good morning or good
afternoon," the practice name, his/her name, and "May I help you?" Another good way to
convey patient interest is the continued use of the patient's name throughout the
conversation. All of us like to be called by name. It is important that the patient is called
by his/her surname unless the patient asks to be called by his/her first name.

Patients cannot always evaluate the clinical care that is given to them, but they can and do
evaluate the personal attention and "common courtesy" shown to them. Discuss the
importance of welcoming and listening to patients. Also, discuss ways in which your staff
can communicate better with your patients. Examples may include:
1. Courteous and respectful language.
2. Telephone reminders of the patient's appointment hour.
3. Written appointment reminders.
4. Attention to appointment scheduling system.
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5. Monitoring of delays in the schedule.
6. Encouragement of patient questioning.

The personal appearance of a staff member can inspire confidence or it can convey a poor
attention to detail. This is also true of the physical appearance of your office suite. Some
practical things to consider are: cleanliness, interior decoration, comfortable furniture,
lighting, and foot health related reading materials.

The APMA produces a wide variety of foot health literature, including numerous patient-
oriented foot health brochures. The APMA brochures can be helpful to your patients in
understanding many foot health issues, including proper foot care, foot and ankle injuries,
bunions, corns and calluses, fungus infections, the diabetic foot, the arthritic foot, and the
reimbursement of foot services under Medicare to name but a few.

FOR APMA BROCHURES CONTACT:

The American Podiatric Medical Association (APMA)
(800) ASK-APMA; Attn: Audio/Visual Membership Services

The best way of finding out how patients feel about your services is to ask them.

You may wish to periodically survey your patients concerning their satisfaction with your
services. Practice management consultants often recommend a single sheet questionnaire.
A good questionnaire opens with a statement of purpose. You may wish to state your goal
of service excellence, e.g., "My goal is to deliver the best care possible..." Included in your
statement of purpose would be a direct request for their comments and suggestions. A
good questionnaire asks specific questions about a practice, e.g., telephone and office hour
availability, the appointment scheduling system, the courtesy of the staff, the office
appearance, the office wait, the care given, the specific patient instructions, and the fees
and billing system.

How do you write the questionnaire? Some consultants recommend the use of direct
statements, alternating between positive and negative statements. All suggest that the
statements be phrased in the third person, e.g., "the staff answers my calls courteously and
promptly"; "the nurse or physician gives me instructions that I understand." Identifying
staff may discourage honest answers. If you use the statement method, you will want to
ask your patients to agree or disagree with the statements by using a rating scale. One
method is a 7 point scale ranging from +3 for those who strongly agree or disagree to -3 for
those who strongly disagree.

Other consultants suggest open-ended questions, leaving blank spaces for the patient to
state his/her opinions. Many consultants recommend that the questionnaire conclude with
an opportunity for the patient to briefly state his/her general recommendations, e.g., "What
I'd recommend to improve...or what I'd like to see changed...."

Ask your patients to mail the questionnaire back to you directly by a specific date. For your
patients' convenience, include a pre-addressed and stamped envelope. You may wish to
close the questionnaire with a note of thanks and your signature. Confidentiality can be
emphasized by avoiding patient identifiers. After you review the results, it is good to send
your patients a letter expressing your appreciation for their help. This letter also can
emphasize your commitment to service excellence by outlining any changes which you are
implementing as a result of their completed surveys.

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In addition, consider placing a sign in your reception area, stating your commitment to
giving the best possible care. For example, you may wish to state: "Welcome to my
practice. As a podiatrist, I specialize in the diagnosis and treatment of diseases as well as
surgery of the foot and its related structures. My services include routine foot examinations
as well as diagnosis and treatment of [complete as appropriate]. I also have a subspecialty
or special interest area in [complete as appropriate]. My goal is to deliver the best foot care
possible. However, quality care depends upon patient participation. Please feel free to ask
questions or make suggestions. Your comments are appreciated." Conclude your
statement with your signature. This statement could also be used in a patient information
brochure, practice newsletters, and print advertisements.

Communicate the benefits of your services to your public begins with selling
yourself to your public.

You are your best public relations agent. The following ideas and approaches may help you
to promote your practice to your public:

Volunteer to speak to community groups, hospital groups, professional
societies, and neighborhood associations.

Become active in professional societies, community groups, and health care
organizations. Volunteer to serve on committees; an especially good one is a
membership committee. Introduce yourself to local community leaders and
local hospital medical and nursing staffs, local health care practitioners,
including dentists, optometrists, pharmacists, and public health nurses.
These are the people who often refer patients.

Get your name and practice in print as much as possible. Write pieces for
patient newsletters, columns or articles in local papers, journal articles.
Create "Helpful Foot Health Hints" pieces. Submit press releases
(informational pieces) to professional society newsletters, local newspapers,
and hospital newsletters. Submit letters to the editor addressing timely
subjects.

Advertise, use paid space to promote your practice. Announce new
developments, e.g., new location, new associate, new services, expanded
hours. Place ads in local newspapers, shoppers' papers, and/or telephone
directories. Develop direct mailers to potential patients in your service area.
The APMA's "Guidelines for Ethical Professional Advertising" is a useful
resource.

Communicate with your patients and referral sources. Send birthday
greetings, holiday greetings, and thank you notes. Many supply companies
offer a variety of contemporary greeting cards, including, birthday greetings,
holiday greetings, get well cards, sympathy cards, and thank you cards. Of
special interest are the appointment reminder post cards, referral thank you
cards, and welcome to our practice cards. Any opportunity you have to get
your name recognized and remembered will be effective.

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Promote your practice through the use of giveaways, including, foot health
brochures, calendars, foot newsletters, or key chains. The APMA's
Department of Public Affairs offers a wide variety of foot health brochures,
including ones on common foot problems, children's foot health, arthritis,
diabetes, foot and ankle injuries, foot health and aging, foot orthoses,
running, walking, jogging, high blood pressure.

Participate in and/or be a sponsor of community health fairs, charitable
events, sports events or school teams, and other programs. Create a
welcome card packet for the local welcome wagon.

Entertain. Sponsor practice "open houses" for potential patients, referral
sources, community leaders, and other health care professionals.

Create a patient information brochure. Use this brochure to introduce
yourself to potential patients. The brochure can answer the common non-
medical questions that patients often ask concerning issues like office hours,
location, billing, and insurance participation. Consider mailing the brochure to
the public in your service area.

Marketing can be challenging, fun, and rewarding. A good marketing plan can help you
communicate your commitment to your patients, create a positive professional image, and
build a growing patient base.

Florida Podiatric Med Assn
page ad
email

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Enhancing Your Patient Relations
The Many Uses of a Practice Management Brochure

What are the advantages of designing a brochure for your practice? A brochure can be an
effective marketing tool, promoting your services, professional credentials, medical
philosophy, location, and payment procedure. The central message of the brochure is to
convey the value of your services to your target audience, e.g., your patients, referral
physicians, and other health care professionals. The brochure must address the unique
needs of the target audience, answering their most common questions and concerns. It
must generate an awareness and appreciation of your services. Thus, the successful
brochure's design and copy expresses the benefits of your services in clear and concise
language.

In developing a practice brochure or with a consultant, the first consideration should center
on the "why" and the "who." Many practitioners choose to design a patient-oriented
brochure first. After evaluating its usefulness, they may design "spin-off" brochures for
other target groups. In designing a patient brochure, consider your patients' first visit to
your office. They may be nervous and uncertain. They probably have many questions
(often unspoken) concerning your hours of appointment, your billing, even your education
and training. A well-designed and clearly written brochure can introduce you to your
patients, state your commitment and express your expectations of them. Patients rarely
evaluate a practitioner's medical treatment, but they can and do evaluate how the
practitioner treats them as individuals. Patients will consider the manner in which they are
greeted by the practitioner and his staff (i.e., whether they are treated courteously,
respectfully, even compassionately). The way in which you and your staff communicate to
your patients often can prevent patient misunderstanding or dissatisfaction. A patient
brochure can create a good start.

A patient brochure may reinforce your patient-oriented philosophy and serve as a personal
Guide to your practice. A prime goal is to create your image as a competent, committed
practitioner available to his or her patients as a specialist in the proper care of the foot and
its related structures. By addressing patients' most common non-medical questions, your
brochure can be an effective educational tool.

Design and write a brochure with the help of all existing resources: your staff, your
colleagues, and other health care professionals. Also give consideration to the format for
distribution. It is best to design a brochure that will limit postage and can slip into
correspondence and patient literature racks for your waiting room or for us with outreach
activities.

Write an introduction and welcome patients to your practice. State your commitment to
your patients and cite the services you offer, including any area of special interest (i.e.,
sports medicine, geriatrics, diabetic foot care). A patient's selection of a doctor is a
personal decision based on various factors. Patients often consider the following factors in
selecting a doctor: the doctor's hospital affiliation, "medical philosophy," professional
credentials, practice structure, and practice location. Include your education and training,
board certification/ eligibility, and hospital or other health care system affiliation if
appropriate.

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The patient brochure should state your policies concerning office days/hours, scheduling of
procedures, practice coverage, insurance, and billing practices. Put yourself in your
patients shoes and anticipate any questions they may have concerning these topics.

The concluding statement should encourage the reader to take an action, i.e., call for more
information or an appointment.

The brochure's copy should be written in simple sentences. It may help if the writer
assumes that the reader has little or no knowledge of the practice. The brochure's
statements must be truthful; hyperbole and exaggeration should be avoided. Many
professional consultants strongly advise against the use of humor. Humor, being
distinctively individualistic, may "turn-off" the target audience. The tone and style of the
brochure should convey the practitioner's commitment and dedication to his/her patients.

When the initial draft is ready, seek the advice of your staff and close advisors. It is
especially important to have someone outside the office (and unfamiliar with your office
procedures and policies), review your copy for clarity. Ask your reviewers if your brochure
conveys your commitment to your patients' well-being and the benefits you provide to your
patients. Does the brochure create a positive response and prompt action?

A well-written and designed patient brochure which addresses your patients' most common
non-medical questions will help to reinforce your commitment to your patients. It will
establish a personal rapport with new patients and strengthen your relationship with
existing patients. It will also promote your practice by creating an awareness of your
services and by clearly identifying the benefits of your services to patients. You may also
use the brochure to serve as the framework for "spin-off" brochures targeted to special
patient groups, health plans, or other professional groups.

Dr. William M. Scholl College of Podiatric Medicine at

Rosalind Franklin University

WW WEE E CONGRATULATE CONGRATULATE CONGRATULATE THE THE THE GRADUATES GRADUATES GRADUATES OF OF OF
THE THE THE CC CLASS LASS LASS OF OF OF 2011 2011 2011

Scholl College leads now for
the same reason it will lead
in the future
the timeless quality of its
forward-looking education.

3333 Green Bay Road
North Chicago, IL 60064
800.843.3059
RosalindFranklin.edu/
WhyPodiatry
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Establishing a Broad Patient Referral Base

Many say that in todays healthcare environment that if you dont grow, you shrink. The
practitioners who are most proactive continue to achieve the highest level of success and
satisfaction. Referrals of patients to an office are the lifeblood of practice prosperity; they
have become all the more important with the advent of managed care. There is not one
model that fits all; however, here are a few ideas for building a referral base and increasing
ones growth potential.

Building a Referral Base for Therapeutic Footwear

Adding a diabetic footwear program to your practice can be one of the most clinically
significant and financially rewarding strategies available to a podiatrist today. More than
20% of podiatrists are currently not dispensing these critically important products to their
patients. A properly facilitated and administered education program in conjunction with
diabetic footwear will result in a significant source of new referral sources, both professional
and patient.

Consider these facts. The diabetic population is rising by 30% per decade. This is
troubling, considering that over 50% of non-traumatic amputations are performed on
people with diabetes. Even more troubling is that over half of these could have been
prevented with timely, conservative intervention, such as footwear and protective inserts.
So why is it that only 3% of diabetic patients are receiving the Medicare benefits for which
they are eligible?

The fact that only 3% of eligible patients are receiving this important benefit is primarily
due to a lack of knowledge, on the part of both the patient and the physician. This
represents an enormous opportunity for podiatrists. By adopting an information-based
strategy, you can easily go into your community and let interested parties know about the
importance of foot health in the diabetic population and about Medicares desire to protect
these at risk patients.

Many practitioners adopt a proactive strategy regarding physician referrals. An informative
letter outlining the danger that diabetic patients face and the role of the Therapeutic
Footwear Program in mitigating these risks should be sent to the entire diabetic medical
team in your community. A necessary step in supplying these patients with their footwear
is a signed certifying statement from their physician. Properly handled, this too can be
another element in your information campaign, while providing you with the opportunity to
establish a working relationship with new referral sources.

Proper advertisement about this service in your office will result in new patient referrals to
your practice. Every one of your patients knows someone with diabetes. By letting them
know that they may be eligible for this important benefit, your existing patients are turned
into community advocates for your practice. Make certain that you have informative
materials available to your patients to take and distribute within their social circles.

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PROMOTE YOUR PRACTICE

P = Patients
R = Radio
O = Other Podiatrists
M = Magazines/Newspapers/Newsletters
O = Organizations
T = Trainers
E = Educational Institutions

Y = Yellow Pages Ad
O = Outside Sign
U = Unique Events
R = Representative from Pharmaceutical Companies

P = Physicians
R = Races
A = All Shoe Stores
C = Celebrate Foot Health Month
T = The Drug Stores
I = Industry
C = Clinics/Hospitals
E = Employees

P = PATIENTS
Past patients are the #1 source of referrals every year. Thank them for sending a card to
all first time patients. You can also send magnets that promote your practice. End of the
year rewards, such as holiday cards, or restaurant vouchers are also a great way to show
patients your appreciation for their continued business, while increasing the potential for
new, word-of-mouth referrals. It is also good practice to have easy access to small facts
about your patients i.e. marital status, recreational activities, local groups/interests, and
children. This information can be used for foster communication and convey your interest
in your patient. Further, when people talk about themselves they think of a friend/family
members who have expressed a podiatric need.

R = RADIO
Radio is a great means of advertising your practice. Volunteer to speak on talk shows,
and/or tape public service announcements. You can even appear on local television shows.
With any media advertising, it is wise to have a catch phrase that you can easily repeat
throughout your segment- your office name, location, website, and slogan are all important
pieces to reiterate.

O = OTHER PODIATRISTS
This may seem odd, but other podiatrists are a great source of referrals. Establish friendly
terms with other podiatrists in your area, especially ones that specialize in triples,
arthroscopy, pediatrics, wound care and diabetic care. Testify to their specific skill, and
they will do the same for you!

M = MAGAZINES/NEWSPAPERS/NEWSLETTERS
These media are another great method of advertising your practice in your community. You
can spotlight shoe sales, feature special health issues, or even feature your practices
brochure.

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O = ORGANIZATIONS
Promote yourself to your fellow community members by getting involved in local
organizations like Kiwanis, Rotary Club and Lions Club. Remember that most of the
patients that are making appointments are females.

T = TRAINERS
Trainers are a great source of referrals for sports-related injuries. Speak to trainers and
coaches at local high schools and colleges. If you have children, young relatives, get
involved in their extracurricular activities there is always a wealth of potential referrals in
this activities.

E = EDUCATIONAL INSTITUTIONS
Start educating tomorrows patient base today! Target young children and explain things
like bee stings, athlete's foot, and warts on slide show presentations. Set up booths that
offer free shoe laces, foot pins and foot-shaped candy.

Y = YELLOW PAGES AD
Place an ad in the yellow pages, mentioning insurance plans, hours and location. Consider
using colored ink or bold black print in the white pages, and advertise to surrounding areas.
Be careful, dont overdo it. Sometimes less is more.

O = OUTSIDE SIGN
Place your logo on a sign outside your practice. Use bright colors, and print in large letters
that are easy to read from the street. Be sure to define yourself as a foot or foot and ankle
specialist.

U = UNIQUE EVENTS
Take part in events that target a smaller population like job fairs, senior health fairs,
diabetes month. Offer screenings for diabetics or set up a booth at the county fair
promotional activity.

R = REPS FROM RX COMPANY
Drug representatives are a great resource for referrals. Some may sponsor advertisements
featuring a drug and your practice or sponsor talks with other podiatrists. If possible, get
involved with their events where you can display your expertise. Most settings are geared
toward other health caregivers nurses, doctors, and medical assistants.

P = PHYSICIANS
Send letters for referrals, even to HMOs. Also, put letters in the hospital mailbox for all
staff members. Attend social events at the hospital, such as holiday parties or staff
meetings to gain physician referrals or host an open house for physicians and their staff.

R = RACES
Volunteer to provide first aid services at races and marathons in your area.

A = ALL SHOE STORES
Promote yourself at local shoe stores. Some retailers take business cards and post them for
customers. Offer coupons to your patients, as well as maps to the stores. Host free foot
screenings and orthotic fittings at the shoe stores, and offer business cards and magnets to
customers.
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C = CELEBRATE FOOT HEALTH MONTH
Advertise free screenings in your office and give patients educational materials. You can get
these materials from your state association or the APMA.

T = THE DRUG STORES
Become friendly with the local pharmacists and give them your business card. Also, be
familiar with the foot-related health products that are available at the pharmacy.

I = INDUSTRY
Offer screenings at your largest local company. Ask if you can leave literature in the break
room or on employee bulletin boards.

C = CLINICS/HOSPITALS
Offer to be on their speakers panel, or to speak at support groups for conditions such as
diabetes, fibromyalgia or Charcot deformity. Place exhibit boards near the elevators in the
hospital, which feature all of the podiatry staff in pictures; also consider volunteering on
hospital committees.

E = EMPLOYEES
Equip your employees with business cards to distribute among their friends and associates.
Fit your staff with jackets, tee shirts and polo shirts that feature the company logo. Also,
consider offering revenue bonuses to promote team spirit!

Dont Forget Opportunities with Local Businesses

Most local businesses and companies are a land of opportunity in which to build a referral
base. Their employees typically have good insurance coverage, and promptly take care of
any medical problems that keep them from working. The word about good doctors spreads
quickly throughout their working environment due to the amount of time they spend
interacting with each other.

A good way to introduce yourself is by sending a letter to the personal director, occupational
health nurse and/or medical director, with your resume or practice brochure attached.
Emphasize that, as podiatrists, we can deliver cost containment. Focus on our ability to
treat sprains, fractures or any injury of the foot and ankle in an effort to return an injured
employee to work as soon as possible. Offer to speak or provide an in-service on topics
appropriate to the industry, such as how to prevent lower extremity injuries and the
importance of proper shoe gear. There can be a focus on preventative measures for their
diabetic employees, as well.

If a company has a newsletter, printed or on-line, offer to write/author articles to contribute
to the column. Most companies host annual health fairs or wellness screenings. These are
an excellent opportunity to gain referrals. If a company does not have a health fair, offer to
organize one. Include blood pressure, glucose and cholesterol checks, hearing screenings,
oral cancer screenings by a dentist and foot and ankle screenings. This is a great way to
introduce yourself and your services to a large population in the community.

Reach Out to Local Physicians

In order to solicit comments and concerns from other podiatrists and their staff, consider
surveying referring physicians on a yearly basis. This shows that you recognize the
importance of your relationship with them and respect their input. If there is an internal
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medicine or family practice residency program at your local hospital, offer to give a lecture
on podiatric medicine and surgery.

Offer rotations in your office for the medical residents, in an effort to further educate them
on the role of a podiatrist in the medical community. Grand Rounds is an opportunity to
address an audience of physicians of all specialties at your hospital. Send a letter to
physicians in your area offering an assortment of pamphlets on podiatric conditions to help
educate their office. Offer to provide copies for patient distribution. Pamphlets should have
a label attached with your name, address, phone number and web site.

A web site is an excellent tool for physicians, their staff and referred patients to learn about
your practice and conditions you commonly treat. Encourage referring physicians to give
the web site to all patients referred to your office. A pad of podiatric referral forms should
be printed and distributed to local physicians. These should include your name, address,
phone and fax number and web site in large letters, the referred patients name, the
referring doctor, the chief complaint (list the ten most common podiatric condition with a
line for other), a map to your office and a line for the referring physicians office to add a
referral number if a written referral is needed.

Marketing Your Practice Base

Have you ever received a post-card in the mail from your dentist letting you know about the
latest dental techniques being used for TMJ? There is a very good reason that you receive
this postcard. It gets patients into the dentist office in an effective and inexpensive way.

Why dont podiatrists use this method of marketing more frequently? Statistics show that
the past patient base is one of your best means of increasing your office volume. Your old
patients know and trust you. They do not represent a cold market. In fact, they are
pleased to hear from you. Here are a few ways to engage in the process of marketing your
practice base:

x Write a letter (usually in October) informing patients that they should make an
appointment to see you before January 1 to avoid paying a deductible.
x Pick a year (i.e. 1999) and call those patients who have not been in your office
recently and ask how their feet are doing. You will be surprised at the number of
people that will make an appointment.
x Send out an office newsletter.
x Send a postcard with a brief description of new treatment methods to all patients
with a relevant diagnosis.

The list is endless, so be creative. Have your staff place follow up calls to your patients that
have received letters. Patients will appreciate your concern.

How to be Your Own Best Referral Source

Your best referral source is a better you. I dont think its a coincidence that when I attend
a podiatry reunion, it is the friendliest and most well respected students that are succeeding
in practice. They had found true enjoyment in giving themselves to the profession, and it
had provided them with more than adequate income in return.

To attract more patients to your practice, you must consider what you have to offer your
family, your community, your place of worship, your staff, and your patients. Dont do this
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in an effort to increase your wealth or bolster your number of surgery patients, but out of
generosity of spirit.

If you have little experience in giving service, then this might be a bit more difficult. Start
small; sit in your waiting room and look around. What could you do to make your patients
and their families more comfortable? Are the chairs padded and easy rising? Is the music
pleasant? Is the reading material current and interesting?

Next, sit in your treatment room chair and look around. Think about what your patients
see, hear, and feel. Are there shiny or sharp instruments lying on the counter, creating
anxiety? Is your burr in a prominent location, making the patient think of dental work? Do
you draw up injections in front of the patient, causing them to become fearful even before
the needle stick?

Spend time listening to what your staff members are telling your patients both in person
and on the telephone. Recently, a senior citizen was scheduled for knee surgery at the
hospital and was told she must schedule her own pre-operative testing. Not only was this
confusing to her, but many of our patients would not be capable of doing this. More
importantly, this patient was not being provided with good service. The same is true of
tedious insurance claims. Long before legislation made it mandatory for a doctors office to
bill Medicare for elderly patients, our office provided this service. We had learned how
confusing and difficult it was for many people to send in their own claims, especially to the
secondary insurance company.

Once youve looked closely at developing a patient-oriented practice, then you can look
outside the doors of your office. Do you volunteer for any charitable organizations? It isnt
enough to spend five minutes writing a check that will be deducted from your taxes.
Donations are nice, but to volunteer your valuable time is an even more charitable effort.

One example would be to get involved with local scouting programs. These activities
consume a great deal of time but they create many good memories for us. The experience
also taught my children that service is an important aspect of living in this world. Some of
our service activities included cleaning up parks, working at the recycling center, collecting
canned goods for our local food pantry, playing with children with disabilities at a local
preschool, and holiday carols at nursing homes in the area.

There are many ways in which to service the profession, as well. Numerous podiatrists give
freely of their time to help improve podiatry through such organizations as the APMA and
state associations. Others volunteer their medical services nationally and internationally.
These podiatrists are giving back to the profession, while actively working to make the
world a better place. I feel certain that if you meet some of these individuals, you will find
an interesting pattern. Each of these doctors is likely to have a full schedule of patients and
more wealth than they need. The generous nature of these men and women simply attract
patients to their practices.

When faced with a new patient, I encourage students to refrain from asking themselves
question like, How many x-rays, surgeries or other services can I provide to help pay off
my student loans? Instead ask, How can I make this patient so satisfied with my care that
they will tell all their friends and relatives?

If you concentrate on money, you will likely never earn enough. But if you focus on the
people you treat and not their insurance carrier, you will find yourself with a steady,
growing income that will never falter even when Medicare decides to drop reimbursements
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by 5.4%. Furthermore, you will have attained the respect, love, and admiration of your
family, your community, and your staff. But most importantly, youll look in the mirror at
the end of the day and feel truly satisfied with the podiatrist that you have become.

A Cup of Honey
Recently, I have taken on the responsibility of verifying patient benefits and obtaining
referrals. I have discovered that this procedure does involve numerous phone calls to PCP
offices, insurance companies and patients (sometimes all three) in order to finally get
results. I quickly got caught up in the monotonous daily routine of making calls, battling
the automated telephone systems, being put on hold, asking the questions prompted on the
prepared form in front of me and practically begging for a decent response. Before long, I
was sounding as painfully mundane as the person on the other end of the phone. Thats
when I turned to an old clich - You catch more flies with honey than you do with vinegar.
I decided to try and turn this problem into an opportunity.

I started using the operators name more often, smiling more during my conversation, and
asking them how they were. I shared my unfamiliarity of the referral system with them,
and basically made the call more personable. Before I knew it, I was getting far more
cooperation than I expected and far more information than I asked for. Tasks that had once
required several initial and follow up phone calls now only took one. The insurance
operators and the referral coordinators in the PCP offices began bending over backwards to
make sure that the data I received was sufficient. Many even provided me with their
extension numbers for future personalized service, bypassing all automation.

Besides receiving more comprehensive information with less effort, Ive literally cut my
telephone time in half and opened the door to developing valuable relationships with PCP
offices.

The ideas presented should be shared with any podiatrists in your office especially the staff
members. Discuss the concepts which can be integrated into your practice and how they
can be implemented. Two months later evaluate the return on investment, fiscally and time
spent putting the idea into practice. Complacency has hurt many good practices and your
best defense is offense. Take every opportunity to spread the word that podiatrists are the
best at treating the lower extremity and your practice is the place to visit.

APMA Sports Literature
Unit Quan. Price Total
Exercise Walking & Your Feet (3003) ______ .30 ______
Fitness & Your Feet (3001) ______ .30 ______
Your Podiatric Physician Talks About
Aging (Code 2001) ______ .37 ______
Arthritis (2002) ______ .37 ______
Athletes Foot (2003) ______ .37 ______
Bunions (2030) ______ .37 ______
Childrens Feet (2004) ______ .37 ______
Diabetes (2005) ______ .37 ______
Diabetes Spanish Translation (2029) ______ .37 ______
Diabetic Wound Care (2034) ______ .37 ______
Diabetic Wound Care
Spanish Translation (2035) ______ .37 ______
Foot and Ankle Injuries (2006) ______ .37 ______
Foot Health (2007) ______ .37 ______
Footwear (2009) ______ .37 ______
Forefoot Surgery (2008) ______ .37 ______
Hammertoes (2032) ______ .37 ______
Heel Pain (2010) ______ .37 ______
Peripheral Arterial Disease (PAD) (2036) ______ .37 ______
Nail Problems (2013) ______ .37 ______
Neuromas (2033) ______ .37 ______
On-the-Job Foot Health (2014) ______ .37 ______
Orthotics (2015) ______ .37 ______
Podiatric Medicine (2037) ______ .37 ______
Rearfoot Surgery (2027) ______ .37 ______
Walking (2016) ______ .37 ______
Warts (2017) ______ .37 ______
Plastic Rack with precounted
assortment of 300 pamphlets (2023) ______ $145 ______
Plastic Rack Only (4010) ______ $45 ______
Assortment Only (refill) (2021) ______ $100 ______
All prices are APMA member prices; nonmembers add 100%.
Subtotal______________
Shipping $5.00
TOTAL________________
I My check, payable to the American Podiatric Medical Association, is enclosed.
Credit card ($10 minimum) I Mastercard I Visa
Number_________________________________________Expires________
Signature ___________________________________________________
Ship to: Name ________________________________________________
Street Address ________________________________________________
City _______________________________________________________
State ____________________________________ Zip _______________
Mail to: Literature Section, American Podiatric Medical Association,
9312 Old Georgetown Road, Bethesda, Maryland 20814-1621
Or Call: 1-800-ASK-APMA, extension 277.
Inform Your
Patients . . .
Inform Your
Patients . . .
Inform Your
Community
With APMA Patient-
Education Brochures
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Winning the Physician Referral Game

With the increased saturation of managed care, the survival of a practice is often dependent
upon physician referrals. These referrals have become the livelihood of many podiatric
practices under various managed care models. Primary care physicians serve as the
colloquial gatekeeper, necessitating the partial redirection of our marketing efforts from
the patient to their primary care physician. Though most podiatric physicians feel beaten up
by the current healthcare environment, managed care has opened the door for savvy
specialists to significantly increase physician referrals. Surveys conducted amongst the
medical community indicate that the most important considerations for a primary care
physician when sending patients to a specialist are the nature of the relationship between
the physician and the specialist, timeliness of feedback regarding the patient visit, and
physician competence. To win the physician referral game you must impress upon them
that you are cost effective and user friendly. But first you must get your foot in the door.

We often become complacent in our relationships with the physicians who refer to our
office. To further strengthen these relationships and make your presence known, have your
staff contact the office managers of the primary care physicians and specialists in your area.
Ask for an appointment, just five to ten minutes during lunch for a formal introduction or to
say hello. This brief meeting is an opportunity to assert your commitment to providing
quality care to their patients and should be followed up with a thank-you letter (Sample A).

Its important to bring the staff some token of your appreciation, such as gourmet cookies
or desserts. You should also ask to leave some business cards. What has been proven to
be very effective is a small pad of referral forms that physicians can use when sending a
patient to your office. This should include your address, phone number, web site address
and a map, as well as a line for the patients name and diagnosis. Another option is to
include a checklist of the ten most common conditions treated by a podiatrist in addition to
a space for other diagnoses.

Another valuable tool is the Lunch and Learn. This is a program presented to the staff of
a physicians office in your community. Select a knowledgeable assistant with first-rate
communication skills to contact the manager of the physicians office. Your assistant should
offer to bring lunch for the office staff to enjoy while listening to a short presentation.
Lunch can be followed by dessert and a question and answer session about conditions that
podiatrists commonly treat. Present the office staff with a professional packet that includes
a laminated list of contracted insurance plans and physician ID numbers, a pad of referral
forms, brochures on the training of a podiatrist and the conditions we treat (available from
the APMA), a comprehensive booklet on foot injuries and surgery rolodex cards with foot
and ankle care on the tabs and a brochure specific to your podiatric practice.

Though the podiatrist can also attend these lunches, the office assistants might better relate
to a member of your staff. The physicians can also be invited; they may prove to be
interested and attentive. Limit the lunch to 30 to 45 minutes, after which your assistant
thanks the office for their time. Have your assistant leave the staff with his or her own
business card so that he or she may serve as a point of contact in your office. Consider
giving that particular staff person the title of Physician Liaison. A handwritten card should
be written to the office manager thanking them for the opportunity to meet with their staff.

During the holidays, gifts to physicians and their assistants are a nice way to send a holiday
greeting. Though chocolate and treats are appreciated, a gift that can be used year round
serves as a marketing opportunity. A good option is to distribute tee shirts. Choose a
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catchy phrase, such as We are the Sole Authority, to be displayed on the front of the shirt.
Make sure to include your name or that of your practice in small print. Contact nearby
physicians offices and inquire as to the total number of doctors and assistants in the office.
A box of gummy or chocolate feet in conjunction with the shirts will make a nice holiday
basket. Have a member of your staff personally delivery the baskets to individual
physicians offices so that additional introductions can be made.

When a physician or a skilled medical professional of any specialty opens or joins a practice
in your area, send an introduction letter along with one of your cards. Two referral sources
that are often overlooked are chiropractors and physical therapists. Welcome them to the
community and inform them of your office protocol. Indicate that a brief report will be sent
to them when one of their patients consults you. Relate that a complete history and
physical is taken at the initial visit and that they will be contacted if medical complaints
have developed. Mention that you welcome an opportunity to meet with them in their office
or for lunch. Offer to provide an in-service lunch for their office. Focus on biomechanics
and its relationship to the entire lower extremity and spine as well as its relationship to the
development of the most common foot and ankle complaints and deformities we treat.
There is a significant opportunity for referral to your office, especially for biomechanical
abnormalities and leg-length discrepancies.

Once you have introduced your practice to medical community, you must maintain your
relationship with its members. Communicating with referring physicians about the
treatment of their patients is the most critical factor in building and maintaining a winning
relationship. If patient reports are sent to physicians in a diligent manner, the bottom line
of your practice will be positively affected. Referral plans mandate that a report be given to
the referring physician before subsequent referrals are made. When a patient is referred
and theres no communication with the referring physician, or when a referred patient is
treated without the knowledge of their physician, your relationship with the primary care
physician can be adversely affected.

If podiatric referrals were not a part of their training, then it would be your responsibility to
create a link between their office and yours. The timely receipt of patient report letters will
help to acquaint primary care physicians, specialists and medical assistants with the scope
of our profession and the professional way in which we conduct our practices. Most
physicians prefer a concise report, whether it be dictated or in reporting form (see Sample
B). Physicians are inundated with paperwork, and therefore not impressed with a three-
page report that they do not have time to read. There are vital pieces of information that
concern the referring physician, such as the chief complaint, diagnosis and treatment,
including medications prescribed (see Sample C). Avoid podiatric jargon that is likely to be
meaningless to the physician.

If an established patient comes in with a new condition, another report should be
generated. A report should be generated for every new patient, not just referred patients,
with a modification to the letter as noted at the end of Sample C. An additional benefit of
sending letters to physicians is that they will know the patient has been to your office. The
physician will often ask the patient how their foot or ankle is feeling. The patient acts as a
goodwill ambassador, as they express their satisfaction with your office.

When surgery is performed, send the primary care physician a copy of the operative report
along with a brief cover letter (see Sample D). The operative report is a valuable
educational tool for several reasons. It informs the physician as to the nature of the
treatment administered. If the report is well detailed, it informs physicians as to the
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surgical techniques and precautions that are employed by podiatric surgeons and puts you
in concert with other surgeons.

It is also important to forward a copy of any blood work and radiology tests performed
outside the office to the referring and primary care physician. If there is a significant
abnormality, call the physician personally to discuss the results. Do not have your assistant
call and place the physician on hold, as it implies that you think your time more valuable.
Making the call yourself shows your respect for the physician and your genuine concern for
the patients well being. It also gives you the opportunity to develop a positive relationship
with their receptionist, which further aids in referrals.

Try to ensure that the referring physician receives all reports within 72 hours. Faxing your
report is an efficient, cost-effective method of realizing this goal. Faxing reports is a more
timely approach than sending mail. The letter can be faxed directly from the transcriptions
office to avoid postal delays and charges. Furthermore, a fax is much easier to handle than
a mailed letter. Faxing a report results in less effort on the part of the referring physician
and a cost savings for your office.

Tell your patient that a report concerning their progress is being sent to their physician to
keep their medical file up to date. Most patients are appreciative and impressed that this is
being done once they are made aware of it. On your new patient form include the
statement, As a service to you, we will send a report to your physician(s) about your foot
problem and our treatment plan. This is part of ensuring that your groups patients and
other customers are satisfied, and a satisfied patient will mean more referrals. Remember
the 80/20 rule: 80 percent of patients come from 20 percent of referral sources. Lets also
not forget that gatekeepers must often choose one podiatrist for capitated plans, and they
typically will select one with a good track record.

Patience is a virtue when playing the referring physician game. When you begin to focus on
physician referrals do not expect an immediate flood to ensue. Conduct an annual survey of
physicians offices in order to solicit their comments and concerns. This shows that you
recognize the importance of your relationship with them and respect their input. If there is
an internal medicine or family practice residency program at your local hospital, offer to
give a lecture on podiatric medicine and surgery. You might even suggest rotations in your
office for medical residents to further understand the role of a podiatrist in the medical
community. Credibility takes times to develop, but the repetitive nature of your efforts will
score the goal.

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Sample A

Sample of Follow-up Thank You Letter

Date:

Madison Tralka, MD
123 Main Street
Garfield, Kansas 08817

Dear Dr. Tralka:

Thank you for the opportunity to meet with you last week. Our office has been located on
Route 9 in Howell for 12 years and my partner, Dr. Nancy Sullivan, and I are available to
treat patients six days a week including three evenings. We participate in most managed
care plans which are detailed in a list given to your staff.

I am Board Certified in foot surgery and affiliated with Jersey Shore Medical Center, Brick
Hospital, Kimball Medical Center and the Center for Special Surgery. We provide a wide
range of services including general podiatric care, x-rays, custom made orthotic devices,
hospital consultations and minor and reconstructive surgery performed in the office and
hospital. I have a particular interest in diabetic and wound care.

It is our policy to provide timely reports and updates for patients referred and when
requested by your office, the patient will be seen the same day. Please let us know if we
can provide you or your staff with any educational materials about the conditions we treat.
I hope we have the opportunity to provide quality podiatric care to your patients.

Professionally yours,

Rosemary Drake-Brockman, DPM

Note: For Pediatricians the second paragraph is modified to read:

I am Board Certified in foot surgery and affiliated with Jersey Shore Medical Center, Brick
Hospital, Kimball Medical Center and The Center for Special Surgery. We provide a wide
range of Podopediatric services including treatment of orthopedic structural deformities,
custom made functional orthotic devices, prescriptions for corrective shoe gear, splints such
as DenisBrowne bars and general podiatric conditions including warts and ingrown nails.
An area in our reception area is decorated and supplied with toys for children to feel
welcome and comfortable.

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Sample B

Sample of Standard Reporting Form
to Referring Physician

Date:

Patient:

Dear (referring physician):

Thank you for referring the above reference patient to my office for podiatric care.

Chief Complaint: _______________________________________________

Diagnosis: ____________________________________________________

____________________________________________________

Medications Given: ____________________________________________

____________________________________________

Treatment: ___________________________________________________

___________________________________________________

I will be sure to keep you informed of the treatment of this patient.



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Sample C

Sample of Letter to Physician for Referred Patient

Date:

Madison Tralka, MD
123 Main Street

RE: Jackson Cahill

Dear Dr. Tralka:

Thank you for referring Ms. Anna Love to my office for podiatric care. She was seen for an
initial consultation on (date) with a chief complaint of right heel pain for five months.

Diagnosis: Plantar calcaneal spur, bursitis and plantar fasciitis, right foot

Medications given: Celebrex 200 mg, #30, one QD with no refills

Treatment: Corticosteroid injection and strapping. Use of proper shoe gear discussed
as well as use of custom made functional orthotic devices. RTO two weeks.

Thank you once again for this most thoughtful referral and I will be sure to keep you
advised of significant developments in this case.



Note: For a non-referred patient the first paragraph is modified to read:
I had the pleasure of treating a mutual patient, Mr. Jackson Cahill who was seen for an
initial consultation on (date) with a chief complaint of right heel pain for five
months.

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Sample D

Attached Sample of Letter of Operative Report
to Primary Care Physician with
Operative Report

Date:

Madison Tralka, MD
123 Main Street

RE: Jackson Cahill

Dear Dr. Tralka:

Mr. Jackson Cahill had foot surgery performed at the Center for Special Surgery on
(date). The procedure was performed utilizing local anesthesia with IV sedation and she
tolerated the procedure well.

I have enclosed a copy of the operative report for your records. I will be sure to keep you
advised of any significant developments in this case



enclosure

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Strategies for Internal Marketing of Your Practice

Large corporations have directed their marketing efforts from customer retention to new
customer development. As physicians, we often concentrate too much on marketing
outside the office. As a result, we lose focus of our most powerful marketing opportunity:
your patients overall experience in your office.

When we consider marketing strategies for a medical practice it is important to distinguish
between internal and external marketing. External marketing involves activities that are
usually either print (newspaper, flyers, etc.) or electronic (radio, television and web site)
that are disseminated to the community at-large.

Internal marketing involves those processes that promote your practice through behavioral
activities within the office. When the current managed care environment evolved, most
practitioners recognized that the most effective means of marketing shifted from external to
internal. Patients were no longer motivated towards a particular office due to visual
advertisements, but rather other attributes, and mostly driven by primary care physicians.
A great deal of goodwill may be acquired through meticulous attention to these activities.

Ten examples of effective internal marketing:

1. Strengthening and exercising personal charisma (communication skills)
2. Professional and social interaction with primary care physicians
3. Timely follow-up phone calls to patients
4. Timely reports to primary care physicians
5. Written literature explaining the patients diagnosis
6. A practice brochure/business cards detailing your expertise and conditions treated
7. Maintaining availability
8. A recorded message for callers on hold
9. Maintaining a bright, cheerful attractive setting
10. And lastly, never feel intimidated to ask for referrals from very satisfied patients

Internal marketing is a strong practice enhancement tool. It delivers a far more powerful
punch than external marketing in our quest for highly motivated loyal patients. Its
cost/benefit ratio is one that simply cant be beat.

Some Time-Tested Internal Marketing Ideas

Some of the earliest experiences I had with internal marketing were some of the simplest
ideas. So simple, in fact, that we didnt even use that term. The doctors I worked with at
that time sent birthday cards to patients, especially to long-time patients and to those with
special birthdays. Patients loved that remembrance, and we were amazed to hear that
sometimes ours was the only card that they received. Suppliers have a variety of foot-
themed cards or design your own using computer software.

Holiday greeting cards are also very well-received. Of course we all receive greeting cards
from the radiology groups and the DME suppliers who appreciate and want our continued
referrals, but the ones we really appreciate are from those special patients who include us in
their greeting card lists. Patients also put special value on the cards they receive from the
doctor who cares enough to remember them.

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A dentist I went to for many years sent Thanksgiving greetings instead. He was also a poet
and usually wrote his message in verse, printing it on paper with autumn images. He
theorized that everyone celebrates Thanksgiving, and so everyone could appreciate his
greeting. We always enjoyed his writings and looked forward to them.

Postage is certainly a much greater consideration these days, but perhaps you could make
up the difference by printing your own message on paper you have purchased in bulk. Or
even by designing your own electronic cards and sending them by email to those patients
whose email addresses you have. A small remembrance on a special occasion will assure
that you are also remembered.

Be a Friend to Your Patients

Isnt it nice to get a phone call from a friend who just wants to catch up with you and see
how you are doing? Most people will tell everyone they know about the special phone call
they received for days to come. It will be no surprise to discover that this phenomenon can
work with your patients and can become the cornerstone of a successful internal marketing
effort.

Your practice has a treasure trove of old patients who have been satisfied with the care that
you have given. By simply inspecting your files it is obvious that many patients have been
discharged with a good result and have received no further contact from your practice. The
further back you go, the more patients will be part of this group. Why not get those records
and call the patients? You do not need a particular reason to do so because you are just
calling to say, How are you?

What you can expect is that the patient will be surprised if not shocked that their
podiatrists office is calling. This is perfectly normal. Continue the conversation for a
minute. Let them know you havent seen them in a while and it is a courtesy call. By now
the patient is impressed. The conversation may not even touch on a podiatric complaint,
which is generally the case.

Train your staff to make these calls and do it consistently by year the patients were seen.
You will see a return of many of these woodwork patients in about 6 weeks.

Educate Your Patients About Your Practice

A brag book is another way to internally market a practice. This book will not only show
your patients your accolades and accomplishments but it will show them your community
involvement. Surprisingly, patients will ask the physician to volunteer at certain events.

In our office, our many accolades are exhibited on our walls in the waiting area. We have
many newspaper articles and journals of our involvement and contributions to our
profession. For instance, one of our partners was honored by our hometown newspaper for
his contribution of medical services at the World Trade Center site.

Also, our brag book has many of the groups accomplishments such as board certifications
and appointments in the community. Another associate in our group was a faculty member
at a medical school and we tend to promote that appointment. This appointment gives the
patient a feeling that she is with a specialist and that patient will tell other potential patients
about the scholarly attainments of our group.

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As patients read these achievements, our group has been asked to participate in lectures
and health fairs. We have many certificates of appreciation and many patients can relate to
your community involvement because they contribute or belong to the same organization.
Moreover, this generated a new patient base and revenue. This newly generated patient
base also leads to many patient referrals. A brag book is one of the best ways to internally
market the practice. In conclusion, this special book can be an invaluable tool for the new
practitioner.
Theres No Place Like Home

A home-like atmosphere is another aspect of internally marketing your practice. It will take
me a book to explain how many patients say our office is so comfortable or your office is
a great place to hang out. However, it must be professional.

Lighting is critical in our office and we have plenty of windows to allow natural light and
fluorescent light in the office. Lighting changes the mood of most people and we feel that
this factor exemplifies happiness. Our group is constantly checking lighting for our staffs
area and patients area and we take pride in our lighting. It is nothing more satisfying than
seeing a patient worried and leaving our office commenting on our bright and cheery
treatment rooms.

We use fresh flowers in our treatment rooms and this reveals freshness in our office.
Patients enjoy this and they feel we are compassionate and we pay attention to detail. They
realize that we not only care about them but we care about other things other than
medicine and this gives the patient a homey feeling about our office. Again, this is a
conversation piece and can lead to patient referrals. Patients always comment on our office
environment and we get many referrals from patients who say how home-like our setting is
in our office.

Comfortable, home-like environment will always bring patients to your office. This aspect
will keep patients coming to your office and generate new patients.

In-Office Dispensing for Patient and Profit Building

In-office dispensing is an effective way to increase your bottom line with a variety of fee-
for-service and insurance-reimbursed products. The number of podiatric physicians who
dispense is growing rapidly and this is true in allopathic/osteopathic medicine as well.

The benefits of dispensing are financially obvious but are eclipsed by improved patient
compliance, time savings and overall satisfaction. For more information read the APMSA
New Practitioners Guide section Durable Medical Equipment and Orthotics.

We Have Two Ears and One Mouth for a Reason

Listening is one of the most important skills necessary to help us hit a home run with
patient satisfaction. That is why we have two ears and one mouth. There is a significant
cost for correcting errors resulting from poor listening skills. There are several benefits of
listening for your practice:

x Listen to others and they will listen to you
x Learn more and with greater accuracy
x Gain each others trust
x Improved employee retention and satisfaction
x Reduce mistakes
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Patients have come to expect that doctors and staff are poor listeners. Focus on listening
skills throughout your office is an excellent opportunity to provide exceptional customer
service. Listen with your ears, eyes and heart.

Information can easily be dispensed through literature, however, it is the complex and
multi-sensory human quality, once again, that allows people the unique ability to
communicate. How can we communicate to the patient the information they need to
know in a way they are assured of understanding? Ask yourself how you would feel in their
situation. It is important to always put yourself in their shoes and help them understand
what it is that you are trying to relate in the clearest, most sensible way. Start by taking
your most frequent discussions (the overly explained referral process, an explanation of
benefits, various office policies, etiology of common disorders, reasons for appointment
schedule delays, etc.) and dissect them to determine if they can be misinterpreted in any
way and then can them in such a way that every response is clear and concise.

Do You See Enough Kids?

Pediatricians are busy and looking for ways to serve their patients more efficiently. Their
schedules are full of croup, fever, flu and yes, foot pathology. The opportunity to cultivate
podiatric pediatric referrals is present in every pediatric practice nationwide. Here are some
simple techniques you can employ to have a thriving pediatric referral network.

First, decide exactly what it is that you can treat well that is commonly seen in a pediatric
practice. Almost every podiatrist can treat verruca, ingrown nails and pronation. Many
pediatricians have neither the time nor the desire to treat these problems. You can expand
into pediatric heel pain, apophysitis, in-toeing and sports injuries. The key is to market
your skills effectively to the pediatric gatekeeper.

Start your marketing effort with a visit to a local pediatric practice or a pediatrician that you
may know. Go just before lunch at the end of the first session of patients, as it is likely that
you will catch the doctors and nurses available. Physicians are almost always brought back
to the doctors office and promptly seen unlike sales people. We always offer an in-service
to the staff on childrens foot pathology. Focus on the pre-determined pathology that you
will be treating. Ask for referrals. Before leaving, an in-service is scheduled and we leave
our office info card (a business envelope sized card with a picture of the doctors, what
conditions we treat, our location and directional maps) Tell the pediatrician that you will see
their patients promptly and handle any emergencies immediately.

When the pediatrician calls for you to see one of his/her patients right away, offer to
immediately do so before being asked. I assure you it will not go unnoticed. You will see
more patients and soon you will see their partners patients. Keep in mind that when a child
is sick or in pain that the parents become worried and apprehensive. Prompt appointments
help the patient, the parents, the referring doctor and ultimately your practice.

Communication with the patient must be in their terms and age appropriate. I always
explain what is going to happen to the parents and then to the child and ask if everyone
understands. If the treatment will hurt, be honest with the child without creating fear. At
the end of the visit all appreciate a reward (sticker, trinket or Gummy Feet).

Quick Tip When your patient is being treated for verucca, discuss the contagious nature of
warts with anyone else in the treatment room. Give them a free screening on the spot and
encourage the rest of the family to come in for the same on future visits. You will find more
warts and schedule them as patients as a result of your diligence!
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Reducing Waiting Time Through Efficiency

Here are some ideas on how to open your schedule just enough to see a few more
patients daily.

First and foremost, start on time. Have your assistant bring back your first patient five to
seven minutes before the first scheduled appointment so the assistant can help the patient
remove their shoes and converse appropriately and then get the chart back to you.

Another time saver is for you to go through your charts before the day begins. Write a daily
schedule which takes about an hour. Next to each patients name include a treatment plan
along with any instructions for x-rays, taping, injection, orthotic casting, surgical redressing,
etc. By familiarizing yourself with patients charts and setting a daily plans for the day you
may actually see three to six more patients.

Pre-fill all injections at the beginning of the day. Pre-make orthotic casting kits with a
pair of gloves, six strips of plaster, a splatter sheet and the orthotic order form. Doing this
step will allow you to see another patient or two. Also, pre-cut or order ready-made
padding. These few ideas allow you to see seven to 11 more patients a day. You do the
money math.

Barry University
page b/w
Via email

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The Essentials of Web Site Marketing
Contributed by: Officite

With over 100,000 internet searches for podiatrists being conducted every month, having a
customized web site is now an essential element of your marketing campaign. However,
before you or a friend try to tackle this task, it is important to understand the critical
elements of a strong web presence and why you should integrate your new web site into all
of your marketing vehicles. You should also strongly consider hiring a firm that specializes in
developing and hosting customized medical web sites, so you can focus your time and
energy on your new patients and practice.

Your web site is more than an electronic phone book ad

Designed correctly, your web site can attract new patients, educate your existing patients,
improve office efficiency, and differentiate your practice from other podiatrists in your
area. However, in order for your web site to attract new patients, it must be optimized for
the search engines, especially with the latest changes in Googles local search
algorithms. This allows Google, Yahoo and the other major search engines to find your site
and list it high in the search engine results for local search queries. Once potential new
patients find your site, it needs to contain the necessary information to persuade them to
schedule an appointment. To accomplish this, your web site should include: a welcome
statement, credentials and pictures of the doctor(s), facts and pictures of the staff and
office, dynamic directions with a map of the office location, ability to e-mail the office with
questions, online forms, newsletters, hundreds of pages of podiatry-specific content (so
your patients can learn about new procedures, treatments, understand terminology and
read up on relevant medical issues), and case studies so you can promote services and
products offered by the practice and most importantly the ability to request (or book) an
appointment online.

Your web site is the core of your marketing campaign

Leveraged properly your web site can work much harder than any other marketing
vehicle. At the same time, it can make all of your other marketing vehicles work that much
harder. Once your web site is operational, make sure you incorporate your
www.practicename.com (called URL) into all of your other marketing vehicles, including
brochures for health fairs and referrals, phone book ad, local newspaper and magazine ads,
newsletters, on-hold message, signage, radio, TV and especially HMO/insurance listings.
This will set your practice apart from others and encourage new and existing patients to
visit your site for additional information.

What to look for in a web site and online marketing partner

Just as choosing the right location for your practice is vital to your success, choosing the
right web site and Internet marketing company is critical to the ease and effectiveness of
your web site and online presence. As you look for a partner, you should consider a firm
who in addition to the above will provide:

x A turn key program
x A quick turn around
x Flexibility to customize the site
x Inclusion of images, email addresses and on-line forms
x Hosting, email, and ongoing site maintenance at a reasonable cost
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The New Patient Website People
A New WEBSITE Equals
NEW PATIENTS
3,053 new patients!
Greg Renton, Orlando, FL
1,278 new patients!
Robert J. Abrams, DPM, FACFAS, Newhall, CA
962 new patients!
Mitchell Waskin, DPM, FACFAS, Richmond, VA
877.484.7185
www.dpmwebsites.com
Websites starting at

$
995
We Can Manage Your
Entire Digital
Presence
h Customizable Websites
h Advanced SEO
h Pay Per Click Advertising
h Social Networking
h Blog Management
h Google Place Search Optimization
h Patient Reviews Management
Reviews
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x Exclusive look and feel that reflects your style and philosophies

The firm should also have a team of search specialists who understand search engines, keep
abreast of industry changes, and have a fully staffed organization which promptly answers
the phone and your questions. In addition, the firm should have a proven track record
designing podiatry web sites.

In summary, a comprehensive, fully functioning, integrated web site and comprehensive
search marketing strategy will help propel your practice and set your office apart from other
podiatrists. Choosing the right design partner is the first step in the process. Once your site
is up and running, your patients (current and new) and staff will thank you.

Officite
page B/W
Email
VI.
Establishing
and Buying
a Practice
Congratulations on your
accomplishments!
Columbia Foot and
Ankle Associates
Stephen D. Palmer, DPM
Ross E. Taubman, DPM
Congratulations!
e best is yet to come!
Phillip E. Ward, DPM
Pinehurst, NC
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Financing a Podiatric Practice

Upon completion of your postgraduate training, the first thing on your mind will be
beginning your practice. Youve worked through the possible practice options. If youve
chosen to open your own office, the next obstacle will be financing your practice. Banks will
lend you money to handle your practice option choice and to cover your other associated
costs and living expenses. Assess your needs and borrow only what is necessary and
consider consolidating your debt.

How do I get into a situation where I dont bear the entire financial and managerial role
myself? There are several options. First, you find a trusted partner, establish a sound
business plan, and apply for a loan to start a practice. This way, you share the financial and
managerial burdens while having the option to practice as a group. Another option involves
pursuing an associate position offered by a practicing doctor. This has several advantages.
You will enter an established practice with an instant patient base. Generally you do not
have to be concerned with practice management decisions and you leave the office without
the added responsibilities. However, your boss has an expectation that you will generate
substantial income for the practice. The money that you generate goes to the practice and
your salary is predetermined, usually regardless of what you generate for the practice. If
you are not prepared for this disparity in earning potential and actual income, it can be a
disquieting realization that you are making 50% of what you could be were you working for
yourself. Fortunately, if the boss determines that the associate is beneficial to the practice,
most associates are offered the opportunity to become a partner. Partners share the
financial and managerial burdens of the practice, but they also share the financial rewards.

Becoming a partner is similar to making a business investment or buying your own
business. Your willingness to pay a percentage of the practice value ensures the owner that
your are committed to your new role as co-owner. Both of you will benefit from this new
relationship. The owner will receive a lump sum payment from your lender and also enjoys
more time away from the practice for which he/she surrenders part ownership of the
practice. Immediately you share in the profits but also gain a bank loan and managerial
responsibilities.

Another practice option which necessitates financing is the purchase of an established
practice. This scenario involves a considerably larger amount of money to take full
ownership rather than buying only a percentage of the practice. However, you will have a
fair assessment value of the practice, immediate cash flow since the accounts receivables
are yours and a guaranteed patient base. The practice buyout route has relatively
flexible financing options and seller participation.

Now that we have discussed some of the options for financing a practice, lets consider the
actual task of financing. Most banks are willing to lend money but you will need more than
a smile and a clean suit. Banks want to know that they have a sound investment in you and
your practice.

Most banks have their own loan application process, but they are generally looking for the
same things. They want to get to know you, your profession, and your potential for
success. After reading this section, you will have the necessary tools to succeed.

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Five Common Myths of New Practitioners

Along the course of our podiatric education and post-graduate training we experience
information overload. It is difficult to sort out the truths, fallacies and myths. Our forged
beliefs which develop over this period of time are what builds the foundation of our
professional life in practice. The myths we believe as a new practitioner can limit our
potential and create much frustration as we begin our careers.

Myth #1 There is little potential to make significant money in podiatry with the
current healthcare environment.

The days of hanging a sign outside your office and having patients walk through your door
are over. Darwinism now rules in medicine especially with podiatry because of the publics
general lack of knowledge of what we do. The concept of survival of the fittest now applies
and has resulted in more high and low income practices with less in the middle.

As new practitioners you each have the opportunity to be fit and end up with a thriving
practice. You are the best medically and surgically trained group of podiatrists our
profession has seen. This is an important piece of the puzzle but many more pieces must
be coupled to achieve success. The students and residents who spend the time to learn as
much as possible about practice and people management have consistently been the
colleagues with the largest, most profitable practices who articulate how much they enjoy
the practice of podiatry.

Some tips to gain practice and people management skills while a student and resident
include:

x Spend as much time as possible in multiple podiatrists offices. Dont just spend
time with the doctor but also a significant amount of time at the front desk and
billing office if the doctor allows.
x Take a training class on sales at local college or business school training.
x Read all articles on practice management and coding.
x Attend any practice management track or lectures at meetings.
x Attend assistants tracks at meetings you attend. There is a wealth of information
here and will be an eye opener.
x Read books and articles on customer service as well as leadership. Many of these
are also available on tape and CD so you can listen in the car.

Myth #2 You can no longer succeed by starting a new practice just out of
residency.

Years ago opening your own practice just out of your post-graduate training program was
more realistic for many. But by no means are the days of starting a solo practice over. We
continue to mentor many new practitioners who open practices in as we hear saturated
areas and quickly thrive. Some have returned to open an office near their families and
others to researched growing areas with high potential for growth. But the common trait
among these new practitioners was the core desire to succeed. These individuals have a
sense of what it will take to realize those desires, and are willing to pay the price and
prepare themselves for achievement.

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These individuals have positioned themselves for success by being proactive during podiatry
school and in their residency and understanding that knowledge is power. Myth #1
above discusses several ways to gain the knowledge that is critical for starting from
scratch. They spent the time to learn such things as coding and billing, internal and
external marketing, staff relations, office technology, designing an office and patient
relations.

There are several forces which make starting a new practice more challenging. Managed
care plans have limited access to patients through restricting the number of specialists in an
area. It is the savvy practitioner who prospers by aggressively and continually working to
be included in insurance plans but even more importantly markets themselves to the
population which has open access to anyone they choose such as patients with Medicare. A
simple way to learn about the insurance plans in your area is to ask your local hospital and
physical therapy and radiology groups for their lists and contacts. The frustrations relating
to financing can be minimized by forging relationships with the small community banks in
you locale. Your strength is in the loan proposal you present.

Starting a new solo practice is not for everyone. Working as an associate will be the most
practical approach for many. The overriding fear of risk many envision to enter a solo
practice places them in a more comfortable position as an associate. This security is
necessary for many practitioners where they can benefit from the strength of a group
practice. Consider the first couple years as an associate in private practice as a fellowship
in practice management to learn patient and office management. This may be the stepping
stone to best prepare for solo practice and by learning the necessary skills to build a strong,
healthy practice.

Myth #3 The patient is #1.

The adage that the customer is #1 is one of the service rules we have learned about
customer service. But the wisest in business will soon realize that the most valuable asset
and key to success and sanity is our staff. Measure success not only by rapport with
patients, but also through the doctor-assistant relationship. Your success, both financially
and professionally, is exponentially related to your assistants.

A common quandary we see with new practitioners is putting themselves above their staff.
In most cases the staff has been there several years and directly responsible for building
and increasing efficiency in the office. The new doctor joins the group and attempts to
define their territory by alienating themselves from the staff instead of bridging the
relationship. Several seasoned practitioners have the scars we acquired from not knowing
early on the utter respect and appreciation we must show for our employees. Even more
important than your staffs salary is your appreciation articulated daily with a simple thank
you and finding them doing something right.

The primary goal in our practices is to meet and then exceed patient expectations. With the
focus being directed on the needs of the patient, office titles have become unimportant.
Doctors and staff alike have discovered unimaginable satisfaction by helping patients feel
better. We would speak regularly at office meetings about turning the attention away from
ourselves and thinking only about how our actions can improve the overall care that each
patient was receiving in the office. At the end of each day, we all feel more fulfilled and
return the next morning refreshed and excited to face new challenges.

The greatest lesson in working with assistants is that, in working toward a winning team is
that the momentum must start at the top. Our role as the doctor is to coach our team and
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lead by example. In coaching our team we have learned that our attitudes are contagious
and set the tone of the workplace. Through open communication and especially listening to
one another, the office continues to learn from each other and grow together.

Myth #4 Im just getting started and still paying off my debts. I couldnt
possibly afford to hire staff NOW!

On the contrary, you cant afford NOT to! Patients do not care about your debt. Perhaps
your financial situation may have you strapped right now (and for what its worth, some
patients may even recognize that), but when weighed against the amount of money you will
conceivably make as a doctor they feel justified withholding any sympathy for your current
situation. Realize, of course, that to most of your patients (and the general public)
everything is relative and by comparison, your debt is insignificant to their own financial
woes. Add that to the reality that physically sitting in your office 24/7 (so you dont miss a
call) and doing everything yourself is not only a waste of your time but it actually sends out
negative inferences, such as:

x You are desperate for patients and will hook anyone that comes through the door.
x You are too cheap to hire someone and diminish your efficiency for perceived
increased revenue.
x You must be impossible because apparently no one wants to work for you.
x Your practice is unprofessional.

Your professional image is important, and throughout your entire career protecting this
should always be one of your top priorities. Right now, in the early stages of your practice,
you have the opportunity to mold this image which, in turn, will generate not only referrals
but also integrity and respect. Always, think and do whats in the best interest your
practice. This is a very impressionable time for your patients. They literally observe (and
judge) everything you do, so while you are in a position to make a powerful impression.
Train staff to answer the phone, greet patients with a friendly hello, make their
appointment, address their questions and have a strong presence in your office. If its the
right staff person, expect both your credibility (and your pocketbook) to benefit.

But remember to keep things in perspective. You wont need to hire a full-time (or high-
salaried) employee right at the start; however, you may want to consider a personable
relative or friend who is motivated to help you get the practice up and running. Or
consider a part-time student who is looking to initiate a new career. Later, when you get
busier, you will want to get a full-time employee (or move your part timer into a full time
position) and have her/him contribute more to the growth and efficiency of the practice.

So, dont make a habit of answering your own phones, save that typical recorded message
for after hours and put the hook away (try not to appear so eager). Personalize your
practice and hire someone you can trust to manage your practice. Feel confident that in
doing this, you will be taking a positive step towards setting a positive professional image
for your new and exciting practice.

Myth #5 I'll never find the time to market my practice! I'll need to spend every
minute at my office so I dont miss any potential patients.

If you build it, they will come. That is one of my favorite lines from a movie entitled
Field of Dreams and it was the incentive that encouraged the main character to follow
through with his far-fetched plan to build a ballpark. It may have seemed a bit
overwhelming when he started, but he believed in it and worked hard to make it a reality.
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That formula can be as worthwhile for you as it was for him with one slight difference, he
was building a ballpark and youre building a practice. The similarity however, lies in the
fact that he didnt accomplish what he did by sitting at home, waiting for it to build itself.
Neither does building your practice mean staying glued to your office waiting for patients to
knock your door down. If handled correctly, the notion that patients will go elsewhere is a
huge misconception.

Do what you can to schedule your time wisely at the office and understand that waiting for
the phone to ring is a waste of time. From a scheduling standpoint, try to position
appointments as close to each other as possible. This serves two purposes. First, it is likely
your patients may run into each other and will give the impression that your office is
crowded.or at least seemingly busy! Second, with all your patients scheduled back to
back, you now have very shrewdly made some quality marketing time for yourself. Set a
realistic goal that you will spend at least one hour a day visiting one new place. Get out
and meet as many new people as you can in the neighborhood. Now is not the time to be
shy. Schedule visits to schools, AARP meetings, nursing homes, sports clubs and other
doctors offices. Stop in at the hospital cafeterias and introduce yourself to staff, colleagues
and other healthcare professionals. The more that people see you, the more they will start
to recognize you as the foot doctor. If you are serious about building your practice and
are willing to put that extra effort into effective, proven marketing tools, things will start to
happen around you, whether you are physically there or not. Remember, If you build
it...they will come.

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The How, When, Where and Why of Associates and Buy-Ins
John V. Guiliana, DPM, MS
Mike Crosby, MBA

Associate yourself with people of good quality if you esteem your own reputation, for 'tis
better to be alone than in bad company. --George Washington

Over the past decade, the changing economic environment has resulted in a shift in the
podiatry labor market. As recently as the early 1990s, the majority of podiatric students
aspired to develop and manage their own practice. The more recent challenges associated
with obtaining managed care contracts, as well as the managerial burden involved therein,
now have many students leaning toward an associateship.

While more students are entering the workforce, eager to associate with an experienced
practitioner, many senior practitioners are appropriately reading the writing on the wall
and searching for an associate and future buyer. This synergistic environment has sparked
an acute interest in the how, when, where and why regarding associateships and buy-ins.

The Timing

While the mechanism behind finding the right associate for your practice may be similar to
any other employee interview, there are important fundamental differences that must be
explored. Hiring an associate is a major investment. The objective as well as the timing of
such an investment should be carefully analyzed. Are you hiring an associate with the aim
of taking more time off, or are you interested in achieving some form of practice
enhancement (improved volume, diverse procedural capabilities, etc.)? The following is a
list of questions that should be addressed.
x What credentials should the associate have in order to obtain your goal?
x If the associate is expected to raise the overall patient visit volume, what will this do
to the practices total expenses?
x At what patient volume level is your practices profit margin optimal?
x Is your office infrastructure efficient enough to handle additional patients?
x Is the community in which you practice conducive to growth?
x Are you prepared to manage another physician or perhaps even lose some
autonomy?

The Search

Finding a potential associate often demands the use of outside resources. Podiatry journals
or the numerous on-line resources are a great place to start. There are also private
management companies available that assist in finding a qualified candidate.

Be sure that the prospective associate knows the intent of your hire. Frustrations
associated with the frequently disappearing senior partner can easily be avoided if the
associate expects this up-front. Goals and objectives for the associateship should be
explored during the interview process. While the significance of medical training can not be
overlooked, the candidates people skills should also be assessed. Creating mock
situations during the interview is often helpful in evaluating this skill.

Attempt to find a candidate who matches the corporate culture that your office provides.
Corporate culture includes the personality and philosophy of your office. Assessing the
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candidate within a social environment may assist in this endeavor. Here are some
questions that need attention during this process.
x Does the candidate share a similar philosophy regarding patient care?
x Is the candidate willing and capable of carrying out your objectives?
x Is the candidate comfortable living and working within your community?

The Investment

Aside from your support staff, hiring an associate will likely be one of the largest
investments that you will make in your practice. It should be treated as such. While the
get what you pay for proverb may not be completely applicable in this regard, fair
business policies and adequate compensation methods are critical for a productive
relationship.

Geographical variations of salary exist. That notwithstanding, there are three basic
methods of associate compensation:
Pure salary
Pure percentage of production (based on percentage of income)
*obtain legal advice to be certain that anti-kick back laws are not violated
Salary plus incentive

Solely providing an associate with a pre-determined salary is an employer-weighted risk. It
is difficult to ascertain in advance if the associate will generate enough revenue to warrant
this compensation. In the pure percentage of production model, the associate is taking
more of the risk. He or she is not able to predict if the patient volume will shift or increase.
In the salary-plus-incentive model, both the employer as well as the associate shares the
risk. In this compensation package, the associate is paid a nominal base salary and is
awarded a bonus after a preset threshold of income is generated. The threshold should be
set at approximately three times the base salary. For example, if the base salary is
$40,000 per year, the threshold at which the associate is rewarded a bonus begins at
$120,000 of generated practice income. A percentage (usually 15-25%) of each dollar
above $120,000 is provided as a bonus and may be calculated and paid monthly or
quarterly. This is generally the compensation model of choice. It provides and necessitates
continual feedback as well as an associates active participation in the financial state of the
practice.

Aside from salary and bonuses, there are other aspects of the compensation package that
may be discussed and negotiated. Some of these are listed below.
x Vacations
x Malpractice insurance
x Health insurance
x Disability insurance
x CME allowances
x Dues and subscriptions
x Auto/gas allowances
x Fees for Licenses and Boards, Managed Care Privileges and Hospital applications

The Contract

Associates should be required to sign a contract of employment. By neglecting to draw up a
written agreement, the employer places the arrangement in serious violation of state and
federal regulations, and creates employment law conflicts for both parties. The contract
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should be designed to protect both parties, and should be prepared by a qualified legal
consultant. The following is a list of sections that the contract should address.
x Employment duties and performance
x Terms of employment
x Compensation package (Base and incentive)
x Issues regarding maintenance of working facilities
x Death/Disability/Workers compensation
x Malpractice Insurance
x Issues pertaining to ownership of medical records
x Covenant not to compete / not to solicit
x Termination clauses

The contract should be as clear as possible. The expected duties and responsibilities of the
associate must be detailed. Covenants should be reasonable if they will be expected to hold
up in court. As an example, a reasonable restrictive covenant will preclude the associate
from practicing podiatry during employment as well as after termination from employ,
within a radius of 10 miles of all offices for a period of three years. A covenant will vary
according to the population density. Liquidated damages may also be discussed in the
contract, should the associate breech this covenant. (You should consult your legal counsel
as to the specific parameters that are usual and customary in your state.)

The Responsibility

Once the associate is chosen and the contract is signed, both parties must assume some
responsibilities. The senior practitioner should tirelessly introduce the associate to patients
as well as physicians, expounding upon his/her credentials. Established practice protocols
should be reviewed and mutually agreed upon in order to ensure that both practitioners
essentially practice as one. The dialog and terms used in the presentation of pathologies
and etiologies, as well as the actual delivery of care should be consistent.

The office staff should be educated regarding the associates role. For a variety of reasons,
staff members are often initially reluctant to schedule patients for a new associate. The
precise verbiage to use with patients should be selected and discussed with the staff.

The senior partner has an obligation to provide clear and consistent feedback to the new
associate. Criticize constructively and privately, yet praise loudly and publicly.

Allowing the associate to participate in management decisions gives him/her a sense of
empowerment. Setting quarterly financial goals facilitates the associates aim and
improves productivity. Since trust is a critical ingredient for a long-term relationship, an
open book policy is the only effective way to manage the finances of the practice.

The Buy-In

Whether by an established or new associate, the foundation of a buy-in relies upon
evaluation of the practices worth. Since many associates feel that they have substantially
contributed to the growth of the practice, it is crucial to obtain a qualified appraisal of the
practice as early as possible in the relationship. However, should this not occur, an
alternative would be to agree upon a date of valuation, generally the date of hire. If this
issue is neglected, an associate may feel as though they are buying into their own hard-
earned achievements.

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A practice is generally worth the sum of its tangible and intangible assets. The tangible
assets are those items that can be touched such as equipment, furniture, supplies, etc.
The sole intangible asset of a medical practice is goodwill. In a medical practice, there are
many components that contribute to this value. While the tangible assets are usually fairly
easy to value using current market prices, the intangible assets can be difficult to quantify.
Knowing a practices factors of production helps. The factors of production include such
things as the net collection ratio, visit volume, payer mix, cash flow, effectiveness of the
management, infrastructure, new patient flow, existing reputation of the practice, and the
market share the practice commands. These statistics often help quantify what we often
can only qualify.

In summary, a podiatric practice is worth somewhere between one years gross and one
years owners compensation. An experienced and qualified medical practice appraiser
should be used for the valuation.

The Information

The seller is expected to disclose all clinical and financial information necessary for the
buyer to evaluate his or her risk. The information that may be considered material to the
transaction includes, but is not limited to:

9 Financial statements
9 Tax records
9 Bank statements
9 Debts of the practice (Both recorded and unrecorded)
9 Patient payment records
9 Patient medical records
9 Information regarding any past, present or potential legal actions
9 Documentation of compliance with all regulatory agencies
9 Key managed care contracts
9 Any special employment arrangements (i.e. family members on the payroll)
9 Leases for real estate and/or business equipment

Prior to the disclosure of the above information, the buyer should sign a document of
confidentiality. The purpose of this document is to ensure that the information obtained is
protected from becoming public and exposing the owner to unnecessary public scrutiny.

The Negotiation

In any buy-in or practice merger, there are three issues that must be negotiated. They are:
x The price and the terms of the sale.
x The terms of the employment of the physicians as well as how income will be
distributed.
x Determining how decisions will be made (governance).

The price of the buy-in and its terms are usually inversely related. Do you want a better
price or more favorable terms? Parties negotiating the statement of key issues at the
beginning of the process can not only enhance the process by identifying key issues (price
vs. terms); they also make the process significantly shorter. Associates must have an
understanding for the emotional state of the proprietor, and likewise the owner must help
the associate to appreciate the opportunity being offered and its long-term benefits.
Further, the needs of all parties should be considered, from both a cash flow as well as tax
position. Both parties must understand that the goal is to develop a long term working
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relationship - one that fosters practice growth and enhancement. Preferably, the buyer
should be permitted to pay down at least some of the debt with pretax dollars. This may be
accomplished by structuring a compensation plan with a compensation differential. A lower
compensation is provided to the buyer and the differential is applied to the debt on a pre-
tax basis. However, care should be taken to ensure that the employment documents and
other agreements adequately reflect the intent of the plan, its timing and full
implementation.

Critical to the long-term success of a multi-physician practice is the concept of governance.
Governance is all about balance in the daily operation and decision-making process of the
practice. While the managing partner has the responsibility of prioritizing corporate goals
and objectives, he/she must maintain a subtle balance between those goals and supporting
the other physicians autonomy. Experience, fairness, a keen business insight and a
rational decision making strategy are important characteristics of a successful managing
partner.

During negotiation, it is important that each party clearly states their needs and priorities.
The sellers needs may include:
x Income security
x More free time
x Improved procedural capabilities
x Cash

The buyers needs may consist of:
x Participation in contracts
x Cost containment (economy of scales)
x Freedom from management
x Increase market share

The rationale for listing as well as ranking these needs should be clear. Both parti es should
strive to meet the needs of the other, in order to facilitate the process.

The Consequences

Every transaction has its good and bad consequences. The good consequences are those
that allow the arrangement to last indefinitely, and the bad consequences are those that
prevent the arrangement from flourishing. These consequences should be anticipated in
advance of the buy-in. Therefore, the documents should not only outline the coming
together, but also the process for dissolution of the merger. In the event of a break-up,
this will reduce the potential for chaos.

Here are some factors to consider:
x Will all providers have a balanced incentive to perform? Senior practitioners,
particularly those with a priority of more time off, are often accused of retirement
on the job.
x What if reimbursement patterns should change or reduce? Are you banking on the
current economy for long term success?
x How might a new partner affect referral patterns?
x How might competitors respond? Will the transaction invite new competition?
x What will happen if the relationship does not work? Are there provisions and break
up clauses to protect each party?
x What are the possible consequences of not taking in a partner or an associate? Will
the competition move in this strategic direction in order to gain market share?
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x How will future growth be borne only by the associate?
x Can we easily follow the cash?
x Does the arrangement promote cooperation and trust?
x Is risk clearly outlined?

The Legalities

Practice transactions require a comprehensive review of the circumstances by a qualified
healthcare attorney. Antitrust laws, federal anti-kickback laws, including the Stark Self-
Referral Restrictions, are all beyond the comprehension of most buyers and sellers. A
healthcare attorney will help to navigate the tumultuous waters, and his importance cannot
be overemphasized.

Aside from federal regulations, particular protective covenants should be discussed and
agreed upon.

The protective covenants for the buyer may include:
x Full disclosure of all financial information
x Indemnification from prior acts. (Tail Coverage)
x Maintenance of license, insurability and privileges of the seller (if the seller is to
remain an employee of the practice).
x Full effort of selling physician (if remaining an employee)
x Production standards designed to promote full effort.
x Covenant not to compete or solicit patients.
x Termination clause and notice required upon termination.
x Assets transferred free and clear of any liabilities or full disclosure of any related
liens.

The protective covenants for the seller may include:
x Timely payment
x Certain amount of autonomy for patient care delivery.
x Time-limited clause to back out of the sale should sellers discretion change.
x Termination clause and notice required upon termination.
x Covenant not to compete or solicit patients.
x Full disclosure and warranties as to performance.

The Process

One of the most critical factors is for both parties to set realistic expectations regarding the
process. The process of finding a partner takes significant time. The first try is often
unsuccessful. Secondly, to find the right partner/ associate to negotiate takes patience. The
associate may believe that he or she has the ability to negotiate a deal without professional
assistance. While it may seem easy, the reality is that this process takes at least four to six
months.

Finally, both parties must evaluate the impact of the negotiations on their long-term
relationship and their ability to work together. The process is complex, time consuming,
and requires professional assistance. We recommend engaging professionals, developing a
strategy, and following a plan in order to achieve a successful end result.

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Factors to Consider in Compensating a New Associate

How much should you pay an associate? The answer is almost always the sameit
depends. The compensation of a new associate depends upon a number of economic,
personal and geographic factors.

Since the geographical location often affects salary issues, you should be aware of the
variations that exist. This factor is usually well understood by most associates and
employers.

Starting with the economic factors that you need to consider, each practice is a unique
entity, complete with its own set of financial data. Obviously, paying an associate 50% of
their individual receipts may be acceptable for a practice with a 30% overhead, but it is not
feasible for a practice with a 75% overhead. For this reason, it is necessary to become very
familiar with the important financial data of your practice before trying to establish a fair
salary for a new associate.

It is important that you predict the profit (or loss) that a new associate will bring to your
practice. This is accomplished through the examination of some important data. Start by
determining your average revenue/patient ratio. Divide your collected receipts for a given
period (i.e., 2008) by the total number of patients seen in that time period. You must also
calculate your total costs/patient ratio by dividing your operating costs (minus your
salary/perks), by the total number of patients seen in that time period.

Once you have these figures, you must factor in your personal considerations with regards
to your new hire. What are the duties and responsibilities of this associate according to the
contract, and what purpose are they to serve in your employment? Are you hiring an
associate to allow you more free time, or is their function to promote themselves and
increase volume for your practice? If they will be increasing patient volume, you need to be
able to estimate the cost per patient that you will incur as a result. To do this, you need to
differentiate between your fixed expenses and your variable expenses for a given time
period. Any additional patients will likely add to your variable expenses only, since your
fixed expenses are most likely already paid for and independent of volume.

Once you have determined your variable expenses per patient, you can begin to predict how
many patients a new associate must see per day or per hour in order to break even. From
there, it becomes a lot easier to establish and rationalize a fair compensation package for
the associate. During the initial start up period, the associate will undoubtedly see some of
your patients, thereby reducing your revenue pool. This may be part of your plan,
according to your personal factors. If it's not, don't panic. This initial revenue loss should
be viewed as an investment in the growth of your practice. If the associate is right for your
office, then he or she will eventually begin working to increase the overall practice volume
and revenue.

Once a salary is agreed upon and the duties of the new associate are outlined, consult legal
and accounting professionals in order to draw up a contract. With a solid agreement that is
beneficial to both your associate and your practice, you can begin working together to
achieve your common goals.

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Buying and Selling a Medical Practice
Mike Crosby, President, Provider Resources, LLC

In this article, we will look at common deal structures and key elements that influence the
structure/factors affecting your decisions, and evaluates factors such as economic and
emotional value in the pricing of a practice, and includes information to complete the due
diligence process when investigating a practice for purchase. Todays marketplace is filled
with innovative new arrangements. Therefore, when one considers a practice purchase the
key element may be to look outside the box rather than solely on the price.

Common Structure
The type of business structure that a selling practice has (for tax reporting purposes) will
determine the sellers preference. (Remember, the seller wants to maximize cash regardless
of price.) The table below highlights common selling structures:

Operating Structure (Tax Form) Transaction Preference
C Corporation (1120) Stock Sale
S Corporation (1120 S) Asset or Stock Sale
Partnership (1065) Asset Sale
Sole Proprietor (Schedule C Form 1040) Asset Sale

Key Elements
Each transaction structure has key elements that are important to consider. They are
outlined as follows:
Structure Elements
Asset Purchase Ability to include and exclude assets of
the practice, thereby, affecting purchase
price
Goodwill is deductible (for tax purposes)
by the buyer
Ability to carve-out accounts receivable
Stock Purchase Seller recognizes capital gains except
for amounts assigned to non-compete
All assets and liabilities, both known and
unknown, go with buyer.
Seller is able to recognize capital gains
on sale except for amounts assigned
to non-compete
Buyer loses goodwill deductibility for tax
purposes
Loss of goodwill amortization and
assumption of corporations liabilities
affect purchase price

Factors to Consider
There are many factors to consider when evaluating a potential practice purchase. First, is
a structure that maximizes the cash-flow benefit to the purchaser. The purchase of stock
versus assets may not appear significant when first evaluated on price solely; however,
given the loss of the amortization of goodwill by the buyer, the impact becomes significant.
On the same note, when stock is purchased the liabilities, both known and unknown,
transfer to the purchaser. The key issue becomes: What acts have occurred in the past
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which could now be presented against the corporation that the new owner would have to
defend?

Second, how will the transaction structure support the lenders ability to fund the
transaction? Lenders look for a minimum cash flow coverage of monthly/annualized
personal expenses of 1.25-1.5%. With an appropriate structure, cash-flow coverage is
maximized, allowing the seller to achieve the goal of getting the maximum for the practice.

Third, define exactly what is being purchased. In a podiatry practice, the fixed assets are
generally not the major component of the purchase price. Generally, the cash-flow of the
practice is the major component and ensuring its transfer is critical to future success.
Therefore, the definition of items included and excluded is critically important.

Economic Value versus Emotional Value
While many are trying to determine their practices worth, others are trying to determine
how much they can afford. Recognizing this buy/sell view, what is the emotional versus the
economic value?

Emotional Value
Most podiatrists have built their practices and early on it was a struggle just to make a
living. However, with hard work and a commitment to deliver quality patient care, the
practice flourished and provided a good income and a recognized place in the local medical
community. Today, emotional value is a part of them; it is an extension of their
professional reputation, and no amount of money is sufficient to meet his/her investment.
Recognizing and respecting this, the podiatrist must be willing to evaluate the practice given
the market dynamics of physical and economic value.

Economic Value
The economic value for a practice can be drastically different from the emotional value.
Economic value is a price/value that an individual can sell a practice to a qualified buyer and
is driven by the ability of the market to support the price through several factors:
x Sustainable revenue stream
x Recognized clinical quality
x Transferable assets: equipment, patient list, managed care contracts, hospital
relationships and referral source satisfaction
x Efficient operating systems/processes
x Market position

These factors affect value by the amount of risk each contributes to the overall success of
the practice. In todays environment many different methods are used to determine the
economic value of a practice. The most widely used method for valuing a medical practice
is the Capitalized Earnings Approach as outlined by the IRS in Revenue Ruling 59-60. While
most of the methods have similar results, the key becomes what the buyer can finance.
Therefore, economic value becomes defined as the amount a practice can be sold to and
financed by a qualified buyer. To estimate your economic value, ask these questions: What
was I able to finance when I started practice? What part of the practice is worth something
to me that means nothing to someone else? Can anyone else replicate my practice? Then
check the market, evaluate the difference, consider the options, and make your decision to
sell, buy or hold your current position.

Due Diligence Considerations
When the decision to buy is made, the process of completing due diligence is a critical first
step. Using the below outline will assist the buyer in evaluating the opportunity recognizing
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his/her ability to produce revenue/make payments for the practice debt. A key will be for
each party to be thoroughly prepared and involved with a competent team of professionals
to complete the purchase and/or sell process.

Practice Background and History
Summary of practice history
Copy of physicians CV/resume
Copies of physician employment contracts, if any
Hours of operation
Physician call schedule
List of managed care plans in which each physician participates
Samples of marketing information
Samples of patient education materials
Copies of stockholder or partnership agreements
List of stockholders or partners, showing the amount of stock or percentage owned by
each person, if applicable
Details of transactions in the companys stock during the last 5 years
Details of transactions with related parties

Personnel Assessment
Listing of employees including job title, date of hire, compensation, and hours worked
Copies of employment contracts, if applicable
Copies of all job descriptions, if available
Copy of personnel manual, if available
Details of employee benefit plans, including pension plans and profit-sharing plans
Copies of pension/profit sharing documents

Accounts Receivable
Accounts receivable aging report at most recent end of month
Annual charges, payments, and adjustments for most recently completed 3 years
Charges, payments, and adjustments by month (and by payer, if available) for most
recently completed 12 months
Charges by payer for most recent 12 months (year-to-date) or as of 12/31/XX
Breakdown of accounts receivable by insurance and patient responsibility as of the most
recent month-end

Regulatory
Reports of examination issued by government agencies such as EPA, OSHA, IRS and
EEOC or HCFA
Copy of CLIA certificate, if applicable
Copy of radiology inspections and registrations
Copy of written evacuation plans
Copy or evidence of HIPPA Compliance

Facility/Ancillary Services Assessment
Copy of office lease(s), if applicable
Charges by CPT code summary for the practice (for most recent month-end and
previous 12 months) access to them (if possible, charges by CPT code for all Medicare
services)

Equipment
Copy of most recent depreciation schedule listing equipment and furnishings owned by
the practice (from the tax return)
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x Description of phone system, including number of phones and locations
x Description of computer system, including hardware, software, terminals, printers, and
their locations
x Copies of significant equipment leases

Financial Analysis
x Financial statements for the most recent three fiscal years and the interim period since
the last fiscal year end
x Copies of income tax returns for the last 3 years
x Schedules showing computation of actual annual compensation of physicians for last 3
years

Outstanding Liabilities
x Copies of loan agreements or notes payable
x Details of any litigation, including pending or threatened lawsuits
x Details of contingent liabilities or off-balance sheet financing (such as letters of credit)
x Insurance and liability coverage and claims history
x Copies of managed care contracts (PPO, POS or HMO) please be sure to have a
comprehensive listing of the managed care contracts to ensure you capture all of the
key contracts and their provisions

Financial Systems
x Copy of any financial analyses already performed on the practice
x List of future capital requirements

Physician Productivity
x Production report containing charges and volumes by CPT code, by physician for most
recent 12 months
x Scheduled office hours to see patients for each physician by location

Billing and Collection
x Written policies and procedures for collections and billing (if available)
x Encounter form or superbill
x Samples of patient information form and hospital charges sheets
x Sample of patient billing statement
x Listing of all adjustment codes

Patient Analysis
x Actual or estimated active patient charts (patients seen within last 3 years)
x Production report containing charges and volumes by CPT code, by physician for most
recent 12 months
x Encounters by physician for most recent 12 months, year-to-date
x Summary of active patients by residence zip code, if available, from computer system
x Summary of active patients by age, if available, from computer system

Medical Records
x Complete a review (using selected charts) to determine the adequacy of documentation
in the medical record supporting patient encounters.

(800) 556-5572
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Believe in style.indd 1 11/10/2010 2:27:44 PM
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233

233
More Than Money
Mike Crosby, President, Provider Resources, LLC

In todays competitive job market employers are looking for ways to create loyalty and
retention in the work force. One of the most compelling methods is by offering incentives
and certain non-cash benefits to employees. Therefore, when considering job offers,
consider more than just the cash.

Lets evaluate offers and determine if any of the offers present a superior offer versus
another.

Scenario #1 A new associate is offered a starting salary of $100,000 with no incentive
clause. The contract is for a one year period. The benefits in include fully paid insurance,
malpractice insurance, two weeks vacation, CME (up to $1,500) auto allowance (500/mo)
and cell phone service. There are no production targets and the contract has a 60 day out
clause for both parties.

Scenario #2 A new associate is offered a starting salary of $60,000 with a bonus of 30%
once collections, (in the year) based on his production, reaches $180,000. The contract is
for three years and has an escalation clause for years 2 and 3 (in both salary and bonus).
The benefits include fully paid health insurance, malpractice insurance, two weeks paid
time-off, CME allowance (up to $1,500), cell phone service, and an auto allowance of
$500.00 per month.

Scenario #3 A new associate is being offered a compensation plan of 55% of their
production (collections). The practice will not pay for any benefits or time off (no work-no
pay).

In order to compare we are going to make the following assumptions:
The practice is well positioned to grow and future opportunities for equity are
similar.
The practice is highly successful and there is significant pent-up demand for
a new doctor and in the first year the doctor will collect $400,000.
Category Offer #1 Offer #2 Offer #3
Guaranteed Compensation $100,000 $60,000
Incentive 0 $66,000 $220,000
Total Cash $100,000 $126,000 $220,000

Benefits (Value)
Health Insurance $5,500 $5,500 (5,550)
Malpractice $3,000 $3,000 (3,000)
Vacation
CME $1,500 $1,500 (1,500)
Cell Phone $ 750 $ 750 (750)
Auto Allowance $6,000 $6,000 (6,000)
Taxes (15%) _______ ______ $33,000)

Net Deal $116,750 $142,750 $170,250

When evaluating offers be sure to consider all the components not just the cash. As noted
above, lower risk yields lower rewards.

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Employment Agreement

This Agreement made this ___ day of April, 2011, by and between Bailey Hoffman,
DPM P.A., a Texas corporation (the "Employer") and Timothy Tralka ("Employee").

W I T N E S S E T H:

WHEREAS, the Employer desires to employ Employee and Employee desires to be
employed by the Employer upon the terms and conditions set forth herein.

NOW, THEREFORE, in consideration of the premises and mutual covenants herein
contained, it is agreed as follows:

Employment. The Employer hereby employs Employee as a podiatrist and Employee
hereby accepts employment by the Employer upon the terms and conditions herein set
forth. The place of employment shall be at the Employer's principal office or at such other
location as the Employer may designate.

Term and Annual Renewal. The term of this Agreement shall commence as of the
effective date of this Agreement, and shall expire one (1) year from the date hereof, unless
sooner terminated as herein set forth. This Agreement shall automatically renew for one
(1) year periods following the Agreement's initial term unless either Employer or Employee
gives written notice of the termination of the Agreement within the sixty (60) day period
preceding any renewal date of the Agreement.

Duties. The Employee will, during the initial and any subsequent term of this
Agreement:

A. faithfully and diligently do and perform all such acts and duties and
furnish such services as the Employer shall direct, and do and perform
all acts in the ordinary course of the Employer's business (with such
limits as the Employer may prescribe) which are necessary and
conducive to the Employer's best interests;
B. devote his full time, energy, and skill to the business of the Employer
and to the promotion of the Employer's best interests, except for
vacations and absences made necessary because of illness;
C. complete medical education courses and annually complete training in
patient relations/relationship management and interpersonal skills
development.

Compensation. Subject to the provisions hereof, the Employer shall pay to Employee
the following for all services to be performed by Employee during the initial and any
subsequent term of this Agreement.

A. Salary. A fixed salary shall be paid to the Employee at the rate of
35% of collected charges for services rendered per annum (which may
be increased at the Employer's discretion), payable in equal monthly
installments. All such payments will be subject to such deductions as
235

from time to time may be required to be made pursuant to law,
government regulation or orders, or by agreement with, or consent of,
Employee.
B. Benefits.
[i] Employee shall be entitled to participate in such life insurance,
disability, medical, dental, auto reimbursement/leasing, pension and
retirement plans and other programs as may be approved from time to
time by the Employer for the benefit of its employees.
[ii] Employer shall maintain a life insurance policy (the "Life
Insurance") on the life of Employee for $300,000 In the event of
Employee's death, the proceeds of the Life Insurance shall [i] first, be
used to pay off any remaining debt evidenced by the Promissory Note
executed of even date herewith by Employee payable to the order of
Bailey Hoffman and [ii] second, any remaining amount shall be paid to
Employee's estate.
[iii] Employee shall provide at his own expense benefits listed on
Exhibit A.
C. Disability. In the event that Employee is permanently disabled, as
herein defined, for a continuous period of three (3) months, the
Employer may terminate this Agreement upon written notice to
Employee. In the event of such termination, Employee's
compensation set forth herein shall continue for the lesser of: (i) any
waiting period set forth in any disability insurance policy maintained by
the Employer and covering Employee, if any, or (ii) three (3) months
after termination of this Agreement.
For purposes of this Paragraph, "permanently disabled" shall mean a
condition resulting from bodily injury or diseases or mental disorders
such that Employee is prevented from performing the principal duties
of his employment. The Employer, in its discretion, based on
competent medical advice, shall determine whether Employee is and
continues to be, permanently disabled for purposes of this Paragraph.

D. Within 30 days following the end of each fiscal year of the Employer,
Employee will receive a share of the Profits equal to his ownership of
common stock of the Employer. Profits shall be defined as the
remainder of collected revenues after business expenses and physician
employment agreement payments have been satisfied.
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Termination. This Agreement shall terminate upon the occurrence of any of the
following:
A. Death. On the date of the death of Employee;
B. Disability. On the date that the Employer gives written notice to
Employee that the Employer is terminating the Agreement;
C. End of Term. On the expiration of the then existing term following the
date either the Employee or the Employer gives written notice to the
other party of his or its election to terminate the Agreement pursuant to
Section 2 of the Agreement; or
D. Termination For Cause. On the tenth (10th) day after the Employer gives
Employee written notice of a Termination For Cause hereunder.
In the event of termination under Subsections (A), (B) and (C) of this Section 5, the Employee
(or his estate) will be entitled to the Annual Salary, to the extent unpaid, set forth herein,
prorated from January 1 of the year of termination to the date of termination. In the event of
termination under Subsection (D) of this Section 7, the Employee will forfeit all benefits
payable under this Agreement.

Termination for Cause. Notwithstanding any other provision of this Agreement, if the
Employee is discharged for cause, or violates Article 7 ("Confidentiality") or Article 8 "Non-
Competition") of this Agreement, then Employee, shall immediately forfeit any and all rights
and benefits under the terms of the Agreement.

For purposes of the Agreement, a discharge for cause shall consist of a termination of
Employee's employment with the Employer for any of the following reasons:

(i) Employee's conviction of any criminal violation involving dishonesty, fraud
or breach of trust;

(ii) Employee's willful engagement in any misconduct in the performance of his
duties which materially injures the Employer;

(iii) Participant's breach of fiduciary duty involving personal profit, willful
violation of any law, rule or regulation (other than traffic violations or
similar offenses) or final cease-and-desist order;

(iv) Employee's performance of any act which, if known to the customers or
clients of Employer, will have a material and adverse impact of the
business of Employer; or

(v) Employee's willful and substantial nonperformance of assigned duties,
provided that such nonperformance has continued for more than ten
(10) days after Employer has given written notice of such
nonperformance and of its intention to terminate Employee's right to
benefits under the Agreement because of such nonperformance.

Any denial of rights or benefits pursuant to this Article 6 shall be made by Employer's Board of
Directors in their sole discretion, applied in a reasonable, good faith manner.
7. Confidentiality. The Employee recognizes and acknowledges that he will
have access to confidential information of the Employer and of entities affiliated with the
Employer, and that such information constitutes valuable, special and unique property of the
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Employer and such other entities. The Employee will not, during or after the term of this
Agreement and for a period of two (2) years thereafter, disclose any such confidential
information to any person or firm, corporation, association or other entity for any reason or
purpose whatsoever, except to authorized representatives of the Employer or if ordered to do
so by a court or governmental agency of competent jurisdiction. In the event of a breach or
threatened breach by the Employee of the provisions of this Article, the Employer shall be
entitled: (i) to an injunction restraining the Employee from disclosing, in whole or in part, such
confidential information, and (ii) to terminate this Agreement and re-collect any and all
payments made to the Employee pursuant to this Agreement. Nothing herein shall be
construed as prohibiting the Employer from pursuing any other remedies available to it upon
such breach or threatened breach including the recovery of damages from the Employee.
8. Noncompetition During Employment. The Employee agrees to the
following during and after his term of employment under this Agreement.
A. Noncompetition During Employment. The Employee agrees that at all
times during the term of his employment he will not, either directly or
through the agency of any corporation, partnership, association or agent
or agency, engage in any similar business conducted by the Employer.
B. Violation of Covenant. If any of the covenants set forth herein at this
Article 8 are violated, the Employer, at its option, shall be entitled to: (i)
notify the Employee that this Agreement is terminated, in which case this
Agreement shall be rescinded (and thus terminated retroactively to the
date of its inception); and (ii) demand repayment from the Employee of
all payments made to the Employee pursuant to this Agreement.
9. Non-assignment. This Agreement is personal to Employee and shall not
be assigned. Employee shall not hypothecate, delegate, encumber, alienate, transfer or
otherwise dispose of his rights and duties hereunder.
10. Waiver. The waiver by the Employer of a breach of Employee of any
provision of this Agreement shall not be construed as a waiver of any subsequent breach by
Employee.
11. Severability. If any clause, phrase, provision or portion of this
Agreement or the application thereof to any person or circumstance shall be invalid or
unenforceable under any applicable law, such event shall not affect or render invalid or
unenforceable the remainder of this Agreement and shall not affect the application of any
clause, provision, or portion hereof to other persons or circumstances.
12. Benefit. The provisions of this Agreement shal l inure to the benefit of the
Employer, its successors, assigns, and shall be binding upon Employee, his heirs, personal
representatives and successors, including without limitation, Employee's estate and the
executors, administrators, or trustees of such estate.
13. Relevant Law. This Agreement shall be construed and enforced in
accordance with the laws of the State of Texas.
14. Notices. All notices, requests, demands and other communications in
connection with this Agreement shall be made in writing and shall be deemed to have been
given when delivered by hand or 48 hours after mailing at any general or branch United States
Post Office, by registered or certified mail, postage prepaid, addressed as follows, or to such
other address as shall have been designated in writing by the addressee:

If to the Employer: Bailey Hoffman, DPM P.A.
Attn: Bailey Hoffman
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99 My House Way
Wayback, Texas 51515

If to the Employee: Timothy Tralka, DPM
33 Your Apartment
In the City, Texas 51515

15. Entire Agreement. This Agreement sets forth the entire understanding of
the parties and supersedes all prior agreements, arrangements, and
communications, whether oral or written, pertaining to the subject matter
hereof; and this Agreement shall not be modified or amended except by
written agreement of the Employer and Employee.
IN WITNESS WHEREOF, the parties hereto have executed this Agreement on the date
first set forth above.

EMPLOYER:

BAILEY HOFFMAN, DPM, P.A.

By: __________________________
Title: _________________________

EMPLOYEE:

______________________________
Timothy Tralka, DPM

EXHIBIT A
Benefits Provided by Employee

VII.
Insurance
Congratulations and best of
luck to the class of 2011!
Washington, DC
Congratulations and
welcome to the profession.
Be involved, be active, and
give back!
Chicago, IL
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Insurance for the New Practitioner

The term insurance can produce a feeling of anxiety in the minds of new practitioners. The
following outline and checklist are designed to assist you in determining what your insurance
needs are and how to meet them. Keep in mind that the primary purpose of insurance is to
provide adequate protection for your personal, professional and financial security. For your
convenience, the following is divided into sections to include personal, office and professional
insurance.

Determining the type and amount of coverage to obtain can be confusing. It is best to find an
experienced agent, representative or business consultant to help determine your needs and
locate a reputable company. A personal recommendation or referral from a respected
colleague is a good way to choose such a person. The APMA sponsors a variety of life and
health insurance programs for podiatrists and their families. These plans are offered through a
professional third party administrator appointed by the APMA. Remember though, it is
ultimately your responsibility to educate yourself on insurance matters and monitor your
coverage.

Health Insurance: This is a necessity for everyone. It is less expensive and easier to obtain
when one is young and healthy. Plans are available with varying deductibles and co-
payments. Plans are available through preferred provider organizations such as HMOs and
PPOs and may be purchased as an individual program covering a physician and his/her family
or as a small group, where rates are normally lower and coverage is more comprehensive.
Remember that health insurance is also an attractive benefit for your employees. You may
decide to explore the benefits of a company group policy for yourself and your employees.
You may also want to try to negotiate rates for your health insurance along with those for your
employees to find the best rates available for everyone.

Life Insurance: If you are young and single you may feel that you do not need life insurance
and you may not if you plan to live the rest of your life single with no dependents. If you do
have reasons to purchase life insurance, it is always easier to purchase coverage at a
reasonable rate while still young and healthy. There are many reasons why you should
consider life insurance now, some are as follows, but these are certainly not limited to the
following: 1) You have a family or dependents now, or plan to in the future, who rely on your
income to support a mortgage, schooling, day-to-day living expenses, etc. 2) There is ANY
possibility that in your later years a spouse can become ill and require medical care that
depletes your retirement fund. 3) You plan to eventually have a wealthy estate and you would
like to offset the tax liabilities of passing that estate on to your posterity.

Life insurance comes in two basic types; term insurance and whole-life or permanent
insurance. As the name implies, term insurance covers only a period of time, normally one
year. Coverage can be purchased for benefit periods ranging from one to thirty years of level
term. A young person can buy a large amount of coverage at a low cost. Each year or
bracket of years, the cost of this insurance increases and most term coverage ends when the
insured reaches the age of 65 to 75. Some, however, continue as long as premiums are paid.
At the end of a policy period, or when you leave the plan, you have no residual or investment
interest. Term insurance is very price competitive since you are only paying for the "true" cost
of the insurance. Non-smokers pay less than smokers and women pay less than men. A good
way to compare plans is cost per $1000 of coverage per year. You will want to review the
provision that deals with renewing your coverage at the end of each term. Look for a plan that
offers a renewal period that most closely matches your current need for coverage.
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Whole-life or permanent life insurance differs in that the contract is long term. You agree to
pay premiums over a long period of time, i.e. to age 65 or 99, for lifelong coverage. Your
annual life is considerably more costly than term insurance when you are young because a
portion must be invested to subsidize these low premiums when you are older. This
investment piece is your "cash value" should you terminate the policy. This is a policy to
consider if you are also concerned about estate planning. The cash value of the policy is
usually tax-free as is the death benefit. However, you should look very closely at your
situation and determine which of these products is right for you. Not all WHOLE LIFE policies
are created equally and many critics cite the large fees and costs of whole life policies as
reasons to avoid them. You should be able to sit down with your agent and perform a cost
analysis regarding his or her product compared to other similar products as well as investing in
other vehicles such as the stock market. For example: If a whole life policy had a cash value
of $100,000.00 and was averaging a 7.5% annual return on that value; a stock market
portfolio would need to provide an annual return of 11.5% to be equivalent assuming 35% tax
bracket. This varies based on the tax bracket of the investor. Your financial advisor or agent
should be able to walk you through this in more detail. Whole Life policies are not meant to be
primary retirement vehicles however, with a good product and careful planning it can provide
significant financial upside in your retirement years including a death benefit to your loved
ones.

To assess how much insurance you should purchase you must first figure out what your dollar
contributions are towards you and your familys long-term financial goals. The goal is to
replace the insured persons income, in the event of an untimely death, to an adequate level
so that loved ones do not need to alter their future plans to make up for a lost provider. A
general rule of thumb is that 5 to 10 times the insured persons annual salary would be
adequate coverage. Remember, your situation may be unique and should be accounted for
accordingly. An example would be to add extra for large one time expenses such as college
tuition and/or to pay down mortgage, car loan or credit debt should you have any of these.
Regarding Term Insurance, it is not your responsibility to purchase enough coverage to make
your loved ones rich in the event of your untimely death and you would likely do better
putting the extra premiums towards another investment, especially since you would most
likely outlive your term policy.

All life insurance is expensive if purchased in later years. Some combinations of term life and
whole-life will fit most situations, but each situation is unique. Employers frequently provide
term insurance in amounts related to salary level. There are many hybrids on the market,
which combine term insurance with investment programs, termed Universal Life or Variable
Life. A final comment on life insurance--these products are very price competitive. Shop
around, avoid the extra "bells and whistles", take your time and don't be pressured into
making a quick decision. If you are a two-income family, be sure to insure your spouse.
Diversity is usually in order when considering this tough decision so take the time to research
your needs and research the products before buying. You can usually purchase a combined
term life with some whole life and role the term into whole as you become more financially
secure and need less early death coverage and more long term coverage. However, it does
not usually make sense to purchase a whole policy later in life as many take between 4-6
years to show a significant positive cash value. Lastly, ask lots of questions to your agent.
Have your agent provide you with more than one plan and more than one scenario with more
than one underwriter (the company providing the insurance) and then play those scenarios out
and evaluate the compatibility with your long term goals.

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Disability Income Insurance:

A risk to your income could come from a disabling injury or illness. Regardless if you cannot
practice your profession, either temporarily or permanently, bills still have to be paid. The
answer to this unpleasant possibility is found in disability income insurance. This type of
coverage begins replacing your normal income after some waiting period, normally thirty,
ninety or 180 days for personal long-term disability coverage. It pays benefits for a specific
period of time and frequently pays reduced benefits as you work yourself back into a full
schedule after recovery. When looking at a disability insurance plan, the main feature to key
in on is the definition of disability. You will want the benefits to be paid if you can't perform in
"your own occupation" rather than some lesser definition such as "any occupation for which
reasonably qualified." The maximum insurable benefit will be tied to your current income.
The waiting period and number of years the benefits are paid to you are all options of varying
disability insurance plans. Your choice should reflect your financial situation and ability to
withstand loss of income.

Many companies will sell any occupation which theoretically could deny paying your claim if
for example; you could not be a podiatrist because you lost one arm in an accident, but were
reasonably qualified to be a greeter at Wal-Mart or more realistically, teach at a podiatry
college. Conventional wisdom has been to buy true occupation own occupation or true
own occupation all of which define disability as being unable to perform the principal and
unique duties of your occupation or in other words for your case - unable to be a podiatrist as
defined by your practice supporting your current income. Very few companies still offer own
occupation to podiatry because of actuarial classifications that assign risk to the profession.
The catch is that own occupation would pay full benefits even if you lost a finger and could not
be a surgeon, but were gainfully employed as a foot and ankle radiologist or professor.

Modified own occupation has the same definition of disability only it pays benefits based on
your ability to produce your insured income level. For example; if you cannot perform surgery
because you injured your dominant hand, you would receive full benefits for the term of the
contract until you return to your full scope of practice. If you chose to continue to teach
podiatry, you would receive a prorated benefit based on your new earned income below the
level you previously insured. You may also elect to not return to podiatry and work in an
office; again your benefit is prorated based on your post injury income. Of course you can
stay totally disabled by definition and collect full benefits. You should not purchase expensive
disability insurance with the intent to be able to become another type of doctor and still
receive full benefits in the wake of a disabling (again by definition) event. It is not money well
spent on the extra premium if you truly only want to protect your ability to live at you current
income level and meet your financial demands.

You must also consider the strength of the company underwriting your policy. If the company
you purchase from goes bankrupt while fulfilling its obligations and paying claims; anyone,
including you, who was relying on those benefits is generally out of luck. Some of the bigger
and more established companies are: Guardian, Berkshire, and Northwestern Mutual. It
cannot be stressed enough, the importance of researching these companies and their
products.

It is also important to read your policy. Understand what you are paying for; many policies
will quote lower premiums, but often times they provide less coverage and include more
loopholes to becoming officially designated as disabled. Again, get many quotes from many
sources and approach two separate agents. Disclose to them that you are comparing their
products and ask them to explain any discrepancies between their policies. It is also a good
idea to have a personal attorney review these policies on your behalf.
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You have worked very hard for many years to attain the income you are going to earn. You
should protect that like any other asset (car, house), at least until you are financially
independent. Use this vehicle as peace of mind towards a secure financial future for you and
your family. Hopefully, you will never need your disability insurance, but it is better to have it
and never need it than need it and not have it. Lastly, do not approach this lightly or lazily.
Do your homework, educate yourself, and force those who will gladly take you money to
provide you with satisfactory answers to your questions. Check them against each other and
verify what you are being told by independent sources. Disability insurance should be one of
your lifes most tedious preparations that you never need to call on.

Office Insurance: As you begin your practice, you may either open your own practice or
share office space with another physician. Your insurance needs will vary based on the option
you select. Opening an office will entail either buying a building or office condominium or
leasing space from someone else who owns the building. If you own the building, your office
insurance will include the physical property or building, the office contents, medical equipment
and computer hardware and software programs. If you lease the premises, you will not need
to purchase insurance on the building, but you will need insurance for your contents and
equipment. Whether you lease or purchase your office space, you will also need Premises
Liability coverage. This is a very broad contract that insures you if a patient or a member of
the public slips and falls on your property. This section of coverage also protects you from
personal injury, slander, and advertising lawsuits. The standard limit for liability coverage is
$1,000,000. Insurance companies often package coverage, enabling you to obtain excellent
coverage for a few hundred dollars. Your package insurance will also include employee theft
and dishonesty, non-owned automobile, excess liability and workers compensation.

Optional coverage you should look for are building ordinance liabilities and fire legal liability.
Building ordinance insures you if you need to rebuild after a loss and the fire codes have
changed insurance company to bear the burden of the extra expense to rebuild your building.
Fire legal liability protects you against lawsuits from other tenants in the event a loss
originates within your premises.

Business overhead insurance is another type of disability coverage and works with your
business interruption insurance to provide continuous income for your salary and other office
expenses in the event of a loss. This coverage provides cash to meet overhead expenses such
as salaries and utilities should a covered disability prevent you from earning an income. High
amounts are usually available and payments can begin after a waiting period of either 15 or 30
days.

A final reminder, if you do share office space with another physician, you should be named as
an additional insurer on his/her office insurance policies. Insurance companies usually do not
charge an additional premium to do this and it protects you while sharing space and expenses.
You should obtain a copy of the endorsement and retain this information with your important
documents.

Professional Liability/Medical Malpractice Insurance: Imagine adding another $20,000
to $25,000 on top of the thousands of dollars you've already spent for your podiatric
education. Without malpractice insurance, you could be held personally liable for court costs
and for settlements and damages; essentially paying well over the cost of malpractice
premiums if you are sued. And those are just the average figures. Some of the more serious
suits--and there are plenty--could cost you much more. Purchasing malpractice insurance
makes a lot of sense. But which insurance company should you choose? The company you
245 245
choose should be well-established and financially sound. There are six factors to consider
when choosing a malpractice insurance carrier:

1). Best report management rating - An A.M. Best Company rating of A (excellent)
is considered acceptable. These ratings often gauge the financial stability of the
insurance company.

2). Licensed or "admitted" status- The company should be licensed or admitted by
the state department of insurance to do business in that state. In most states,
admitted status means that if any insurance company goes out of business, the policy
holders are protected by the state's guaranty fund.

3). Availability of claims and loss data- The company should routinely share
program claims and loss information with the state podiatric association. Some
companies publish annual reports, which include this type of data.

4). A sound risk reduction and loss prevention program- An insurance company
that promotes risk management is interested in keeping the cost of claims down.
These savings can then be passed on to the policyholders in the form of lower
premiums. Some companies offer seminars and/or discounts for attending these
programs.

5). Podiatric involvement in the program- A good malpractice insurance program
responds to policy holder's needs. Using committees of podiatrists to review claims and
underwriting procedures adds to the fairness of the program and ensures that the best
interests of the profession are kept at the forefront.

6). Factors for setting premiums- Three main factors that should be considered
when setting rates are the program's loss history, the legal climate in the location of
the practice and the investment history. Programs that insure only low risk doctors are
able to keep rates down, and are obviously more stable. Legal climate is important
because awards vary depending upon the size of a city. The investment history will
determine future rates.

Deciding on Malpractice Insurance Coverage: Malpractice insurance is available under
two main types of policy forms: occurrence and claims made. Most professional liability
insurance is written on a claims-made basis.

Occurrence Coverage: An occurrence policy provides coverage for any incident that occurs
during the policy period, regardless of when the claim arose or was reported. For example, a
claim could be made many years after the initial incident occurred, and as long as occurrence
insurance is current, the policyholder is covered. Occurrence policies take in to account future
projections not on current experience. Occurrence policy rates are based upon the estimated
cost of claims that may be reported in the future. It is sometimes difficult to predict these
costs because of inflation and other factors. Premiums for occurrence coverage are generally
higher than initial claims made premiums. One benefit of having occurrence insurance is that
no tail coverage or retroactive insurance coverage is necessary if you cancel and occurrence
policy.

Claims-Made Coverage: A claims-made policy provides coverage for incidents that occur and
are reported as claims during the policy period. If you terminate your claims-made policy, it is
important that you consider additional coverage (called extended reporting period or tail
coverage) to cover claims that are reported after your policy ended. Claims made rates are
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based on actual claims reporting trends, so rates are more in line with the actual cost of
losses. First year premiums are lower and are often more affordable to the new practitioner.
As exposure to claims increases, rates follow a step-rate scale to maturity. First year
premiums for a claims-made policy could represent up to a 60% savings over the occurrence
rate.

Tail Coverage: Tail coverage policies, often referred to as extended reporting period, covers
the insured for claims that are made after your claims-made policy is discontinued. It allows
the insured to continue reporting claims for the year you were covered by your original claims-
made policy. Tail coverage is typically purchased from the same company you selected for
your claims-made policy.

Prior Acts Coverage: Prior Acts coverage provides the insured coverage for claims, which
arose during the time before the insured was covered under the current claims-made policy.
Prior-acts coverage can be divided into two sub-types: full prior acts or retroactive date. Full
prior-acts coverage covers the insured for acts occurring at any time prior to the current policy
period where as retroactive date coverage selects a specific date where coverage for acts
begins. Unlike tail-coverage, prior-acts coverage is purchased from the new company
providing the new claims-made policy.

Limits of Liability: You will also need to choose the limits of liability for your policy. Limits
are generally stated in two figures. The first figure represents the monetary amount per claim
that the insurance company will pay in one claim; the second is the maximum amount payable
in total claims per policy year. Some common limits are $200,000/$600,000; $500,000/$1.5
million; $1 million/$1 million and $1 million/$3 million.

One factor to keep in mind when selecting limits is whether you will be on staff at a hospital. It
is current practice today for many hospitals to require $1 million/$3 million limits. Consider
too, the value of your assets. Additionally, some insurance policies include legal court costs in
the limits of the liability, while others are covered separately. Selecting the right policy limits
will protect not only your practice, but also your personal assets.

Calculation of Premiums: The calculation of your premium for the various liability policies
are based on a multitude of factors including education, training, experience, American Board
certifications, type of policy and coverage requested, your geographic location, your patient
load, employment of nurses or other health care professionals in your practice, in office
administration of anesthesia, sites where you perform surgery, past claims, your scope of
practice, and your specialty to name a few. Every application for medical malpractice is slightly
different, but expect to find questions relating to a majority of the items listed above.

The Value of Service: Look for extra features and services from your insurance company.
Some companies offer special rates for residents or preceptees. Other services might include
premium financing and flexible payment arrangements. If you have a problem or questions
about your coverage, you should be able to contact your insurance company easily. Look for
accessibility in the form of toll-free telephone numbers and active web sites. If you have a
claim, good communication with your insurance company is absolutely essential.

Consider too, the overall philosophy and performance of your insurance carrier. Is the
program exclusively for podiatrists? How large is the policy holder base? What is the
company's level of commitment to podiatry? Do they support state associations and student
programs?

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Does the company have access to professionals who vigorously defend claims? Is two-way
communication encouraged through podiatric committees, participation in podiatric
conferences and meetings, and through newsletters and other publications?

It's Your Decision: Deciding on a malpractice insurance carrier is much more than shopping
for the best bargain. The company's financial stability, reliability and level of service are all
important factors.

Understanding the scope and level of your own practice, however, will probably help you more
than anything else. Consider the legal climate where you will be practicing. Will your patients
be generally young or old? Will you be performing surgery? Lastly, make every attempt at
ensuring an open and communicative relationship with your patients is often the best way to
avoid the pitfalls of a malpractice suit.

Answering these questions will help you choose the company and the coverage that best suit
your needs. In closing, please remember that all types of insurance are designed to put you at
ease first. Do not let an agent sell you more coverage than needed nor scale down your
coverage to meet a fixed price. There are several books out on the market, which can help
you in determining your insurance position. It is advisable to research your insurance options
six months before you begin your practice. Group coverage, if available, will generally be less
costly than an individual policy. Spending time to shop the insurance market will save you
money.

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Insurance Action Plan

Current Status

Needs Okay or
Action Not Applicable

_____ _____ Review all your insurance coverage annually. Your
insurance agent should orchestrate this review.

_____ _____ Prepare your own estimate of your life insurance needs.
Don't rely on others to do it for you.

_____ _____ Be sure you or your agent gets quotes from several
companies prior to purchasing any life insurance.

_____ _____ If you need term insurance be sure to check on any
coverage that may be available through your employer and
professional groups and associations such as the APMA.

_____ _____ If you have an estate that is likely to be near or in excess
of $l million, check with an estate planning attorney to
assure that you have designated appropriate life insurance
policy owners and beneficiaries.

_____ _____ Be sure that all family members, including parents and
children, have adequate and continuous health insurance.

_____ _____ Evaluate the sufficiency of the amount and the policy
provisions of all disability insurance policies currently
owned or provided by your employer.

_____ _____ If necessary, obtain additional disability coverage. Look for
individually purchased policies with desirable features.

_____ _____ Take an inventory of your household possessions.

_____ _____ Evaluate the adequacy of your homeowner's or renter's
insurance and add to the coverage if you find any areas
that are not fully insured.

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Needs Okay or
Action Not Applicable

_____ _____ If you don't have professional liability for all of your professional
endeavors, inquire as to your potential exposure. Take action to
reduce this exposure if necessary.

_____ _____ If you are considering any action to shield your assets from any
potential medical lawsuits, seek legal counsel in advance.

_____ _____ Obtain an extended personal liability (umbrella) policy if you
haven't already.

_____ _____ Consider increasing the amount of umbrella coverage if you now
have only $1M.

_____ _____ Your insurance agent should be competent and responsive. If
not, make a change.

Important Areas of Insurance Coverage

Type of Insurance Description/Features

Health Protects you from both the out-of-pocket costs of health care
and large cash outflows during major illness.

Homeowner's Property (home),other structures, personal property, and general
contents of the dwelling are insured against theft/destruction; protects
against the possibility of cash outflows for replacement of these
assets.

Renter's Protects the personal possessions of the tenant.

Automobile Protects you from large cash outflows for damages resulting
from automobile accident or theft.

Personal Liability Protects you from having personal assets or future earnings
forfeited as a result of a personal liability suit. Provides
additional protection on top of homeowner's and automobile
liability coverage.

Professional Liability Protects you from claims arising out of professional acts or
omissions.

Disability Replaces part or most of your wage income in the event of
disability.

Life Replaces part or most of your wage income in the event of your
death and covers nonrecurring expenses If your dependents
during a readjustment period after death.

To register, make hotel reservations,
and get more information, visit
www.apma.org/thenational.
OPENING SESSION
Featuring Ross Shafer, six-time Emmy
Award-winning comedian, writer and TV host
SCHEDULE AT-A-GLANCE
WEDNESDAY, JULY 27, 2011
8:30 am Noon Surgical Workshop 1
1:00 4:30 pm Surgical Workshop 2
2:00 6:00 pm APMA Registration
THURSDAY, JULY 28, 2011
7:00 am 6:30 pm APMA Registration
7:30 9:00 am Breakfast Symposium
9:00 10:00 am Plenary Lecture
10:00 am 3:00 pm Scientic Sessions
12:00 1:00 pm Podiatry Managements
Hall of Fame Luncheon
3:00 4:00 pm Opening Session Address
4:00 6:30 pm Exhibit Hall Grand Opening
FRIDAY, JULY 29, 2011
9:00 am 5:00 pm Exhibit Hall Open
5:00 6:00 pm Poster Abstracts Reception
SATURDAY, JULY 30, 2011
7:30 9:00 am Breakfast Symposium (non-CME)
9:00 am Noon Surgical Workshop 3
9:00 am 1:30 pm Exhibit Hall Open
12:30 3:30 pm Surgical Workshop 4
3:30 5:30 pm PICA Risk Management Program
6:00 7:30 pm APMA Final Night Reception
SUNDAY, JULY 31, 2011
7:00 10:00 am APMA Registration
9:30 am Noon Scientic Sessions
The National is a unique value, offering you more CME contact hours (up to 25*) for your dollar
than any other meeting. At The National, youll receive:
Nultiple specialt] tracks, includind surder], sports medicine, wound care, practice
management, podiatric medicine, radiology and more.
PlCA's lardest discount (15 percent more than covers the redistration fee
Breakfasts, lunches and refreshment oreaks included in redistration fee
Complete prodram for podiatric medical assistants (plus, each additional assistant from
the same APMA member practice receives a 25% discount.
The hational 2O11 orinds ]ou a new and innovative lecture series desidned to address the needs
of all podiatrists, whether the] are new practitioners, estaolished, or considerind retirement.
The series kicks-off with a oreakfast s]mposium, "Essential Practice Tools. Buildind Blocks
for Toda]'s Podiatrist," followed o] three lecture tracks desidned to provide tools and tips for
surviving the 21st century practice.
* Up to 25 continuing medical education contact hours. This number is based on attendance at all breakfast
symposia, general session lectures, and the poster abstracts reception.
REGISTRATION
Make your hotel reservation today; the APMA room
blocks are limited. Once the blocks are full, rooms
are subject to availability at prevailing rates.
Podiatric medical students and APMA postgraduate
members receive complimentary registration.
APMA Grad Hdbk Ad_BW.indd 1 3/18/11 2:23 PM
251 251
Malpractice Claims: What You Should Know
Contributed by: PICA Group

Malpractice insurance companies realize that, despite everyones best efforts, professional
liability claims do occur and that bad things can happen to good people. It is also recognized
that the vast majority of negligence suits involve unexpected outcomes rather than
malpractice.

Nature of a Malpractice Claim

Under our civil law system, an alleged victim (the plaintiff) can seek compensation from the
alleged wrongdoer (the defendant) if the plaintiff can establish the following:

x a duty was owed by the defendant to the plaintiff;
x a breach of that duty occurred; and
x that breach proximately caused demonstrable damage to the plaintiff.

When applied to malpractice claims, the three elements to be established become the
following:

x there must be a verifiable doctor-patient relationship (duty owed);
x negligence, in the form of a departure from acceptable medical standards;
x plaintiff must have suffered damage proximately caused by the doctors negligence.

It is the responsibility of the plaintiff, through his/her attorney, to prove that all three
elements exist. Failure to convince a jury of any one of these elements results in a judgment
in favor of the doctor/defendant.

Lawsuits, Claims and Reportable Events

The first notice of a claim can be in the form of a lawsuit or other legal document, such as a
written notice of intent to sue. Formal legal notification of a lawsuit can be served in
numerous ways and varies from state to state. In some states service may be made:
x by a process server who personally serves you with papers. You can be served
anywhere. Service can also be made by leaving papers with a spouse or employee;
and/or
x by the local sheriffs department; and/or
x by the plaintiffs attorney or the attorneys designated representative; and/or
x via the U.S. mail (certified or regular); and/or
x via fax

In addition to a formal legal notification of a lawsuit, there are several situations that should
alert you to the possibility of future legal action. Prompt and thoughtful response to these
situations can many times prevent or substantially mitigate subsequent formal legal action.

What Should be Reported?

Your malpractice insurance company should be notified immediately
x upon receipt of lawsuit papers;
x of any claim (defined as a demand received by the insured for money or services,
including the service of suit or institution of arbitration proceedings against the
insured);
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x upon receipt of a subpoena, a formal command from a court or other governmental
body that requires the recipient to appear at a certain place and time in order to give
testimony and sometimes to provide documents;
x of any event or incident which may result in a claim or lawsuit in the future.

When should a lawsuit, claim or reportable event be reported?

You are encouraged to immediately notify your malpractice insurance company of any
circumstance that you feel could result in a claim or lawsuit against you. Timely and proactive
actions by you and claim professionals can often prevent formal legal action by your patient.
Furthermore, prompt action enables your malpractice insurance company to evaluate the
situation while the facts surrounding the event and your memory of the incident are still fresh.
Failure to promptly notify your malpractice insurance company of any claim made against you
could cause you to forfeit the coverage provided by your malpractice insurance policy.

PICA realizes that the primary role of a doctor is that of a healer. We are committed to
supporting you in your role of healer and will constantly strive to minimize the interruptions
caused by malpractice claims. PICAs ongoing risk management program is dedicated to the
reduction of professional liability claim frequency and severity. We urge you to participate
actively in our risk management educational programs. For more information or a free quote,
visit www.picagroup.com or call us toll-free (866) 742-2477.

VIII.
Ofce SuppIies
and Set-up
Best of luck in the greatest
profession of allpodiatric
medicine and surgery!
Joe Caporusso, DPM
McAllen, TX
Congratulations! APMA
will always be there for you.
R. Dan Davis, DPM
Bridgeport, CT
800.321.9348 www.gebauer.com/apmsa
Provide less
painful podiatry
Gebauers Ethyl Chloride topical anesthetic skin refrigerant is the suggested application
preference for topical anesthesia prior to podiatric blocks and minor surgical procedures
such as ingrown toenails. Only Gebauers non-drug, instant topical anesthetic skin
refrigerants are FDA approved to help control the pain of needle procedures and minor
surgical procedures. There is no waiting as with anesthetic creams. Just spray for a few
seconds. The anesthetic effect lasts up to one minute.
Gebauers Ethyl Chloride is available in the familiar brown glass bottle in Fine Pinpoint Spray
and Medium Stream Spray. The aerosol spray cans are available in Mist Spray and Medium
Stream Spray.
Important Risk and Safety Information
N
Ethyl Chloride is FLAMMABLE and should never be used in the presence of an open
ame or electrical cautery equipment
N
Inhalation should be avoided as it may produce narcotic and general anesthetic
eects, and may produce deep anesthesia or fatal coma or cardiac arrest
N
Do not spray in eyes
N
Over spraying may cause frostbite
N
Freezing may alter skin pigmentation
N
The thawing process may be painful and freezing may lower resistance to infection
and delay healing
N
Cutaneous sensitization may occur, but appears to be extremely rare
N
Long term exposure may cause liver or kidney damage
N
Rx Only
602.1 2010 Gebauer Company Rev. 01/10
The APMA Educational
Foundation Student
Scholarship Fund is the only
national scholarship program
dedicated to helping students
studying podiatric medicine.
The Foundation strives to
award more students with
scholarships each year, which
are instrumental in helping to
ease the financial burden of
podiatric medical school.
Awards are made to third-
and fourth-year students
attending one of the
nine colleges of podiatric
medicine. The criteria used
to select scholarship
recipients are GPA, community
service, school leadership,
and financial need.
Schools of Podiatric Medicine
Arizona School of
Podiatric Medicine at
Midwestern University
Barry University School of
Podiatric Medicine
California School of
Podiatric Medicine at
Samuel Merritt University
College of Podiatric
Medicine at Western
University of Health Sciences
Des Moines University
Medicine and Surgery
New York College of
Podiatric Medicine
Ohio College of
Podiatric Medicine
Dr. William M. Scholl
Medicine at the Rosalind
Franklin University of
Medicine and Science
Temple University School of
Podiatric Medicine
Congratulations to the Class of 2011!
www.apma.org/educationalfoundation
EDUCATIONAL FOUNDATION
Educational Initiative of the American Podiatric Medical Association
Contact Information:
APMA Educational Foundation
Sandra F. Arez
Foundation Coordinator
9312 Old Georgetown Road
Bethesda, Maryland 20814-1621
Tel: 301-581-9244 Fax: 301-530-2752
Established in 1959
as a tax-exempt
organization,
the program has
awarded more than
2,000 graduates.
In 2010 the Foundation
Student Scholarship
Fund disbursed 161
scholarships totaling
more than $195,000.
257 257
Podiatric Supplies

The idea of preparing to open a new practice is daunting, especially right after residency when
youve already amassed a great deal of debt. In hopes of making this process easier and less
confusing, the APMA has created a APMA Buyers Guide to have at your fingertips. The Guide
is one of the easiest ways to find information about products for podiatrists is by using the
"APMA Buyers' Guide-Commercial Reference to the Podiatric Office."

This timely member benefit is easily accessible from the button on the APMA members'
homepage. The APMA Buyers' Guide enables you to conveniently perform targeted searches
for industry-related products and services. Unlike traditional Internet searches that can
generate numerous irrelevant results and slow down your procurement process, the Guide is
filled with APMA-friendly suppliers and service providers, many of whom are also valued
APMSA CAB members.

The Guide is a valuable tool for researching, selecting, and purchasing the industry resources.
You also can search the supplier network directly from your desktop by downloading the
search tool! Visit http://members.apma.org and click the APMA Buyers' Guide logo.
Remember: Please consider APMSA CAB members when possible.

In addition, heres some other useful advice:

How do I decide which supplier to use?

- Prepare an equipment list and send the list to at least two separate supply houses to
obtain the best estimate on equipment (see enclosed list).
- A good way to choose suppliers is to go to a podiatry conference with exhibits where
they have items on display. Look for companies that are willing to go out of their way
to help you. Some companies are willing, at no extra cost, to personally deliver the
equipment and set everything up. Used equipment is also always an option but be
selective.
- It is also important to know how long it will take a supplier to deliver supplies and how
they handle billing. Will the supplier handle the shipping costs? Some suppliers will if
you order large amounts of material. Also, how will the items be shipped? Do they
have next day delivery options? If the supplier has a large stock of items they can
usually ship quickly but if they do not usually carry some items (especially if you are
not using a supplier that caters to podiatry) it can take several weeks. Some suppliers
have various payment methods. Consider which one is right for you.

One must assess many variables when choosing suppliers. To better help you choose, ask
yourself some of these questions. Is the supplier able to handle all the durable equipment and
the sundry supplies needed? Is the supplier you are considering located relatively close to
your office? Will they be able to respond to the unexpected short-term supply needs of your
office? Does the supplier have a long standing and positive relationship with its buyers?

What supplies and equipment should I buy and how much will it cost?

- To save money practitioners can obtain one power podiatry chair and one non-powered
examination table, the latter costs approximately $300 to $400 versus $5,000 to
$6,000 for a power examination chair. Consider purchasing used powered chairs over
buying one power and one non-powered. You might need that second chair faster than
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you think so why buy something that needs replacing so quickly. Used chairs can be
reupholstered easily and cheaply and often come with warranties.
- Buy stainless steel instruments versus chrome plated. Stainless steel will survive better
when autoclaved on a repetitive basis. Quality instrumentation will obviously last
longer and should be sought out when ordering. Also consider obtaining
instrumentation for a surgical pack. When starting ones practice, only two or three
packs would be necessary.
- Depending on finances, dip tanks can be used in lieu of an automatic processor for
developing radiographs. However an automatic processor is preferable despite its
probable cost of around $15,000 (this includes other important instrumentation such as
a Hyfrecator, routine supplies, etc.). Consider digital radiology and digital processing,
this is a more expensive option, however, the technology of the office is moving to
paperless and this may be an expense that is worth it. Not to mention the savings
associated with saving square footage in the office, no dark room, no film storage!
- Buy the bare minimum of office supplies because it is very expensive in the beginning
to keep a lot of inventory that you dont use. Most supplies can be delivered in two to
three days.

What about discounts on supplies and equipment?

- Discounts are available. A 10% discount or more may be negotiated on routine
supplies.
- Prices in catalogs, or the list prices can be anywhere from 40-60% higher than the
actual cost. Send a Pro Forma (which is a list of equipment you are thinking of
purchasing) to the different companies and they will then list the real prices of
everything, so you can get an idea what you will really be paying. Allow competing
companies bid for your business.

Here are some other money saving tips:

- If you move into a community with a large number of podiatrists, investigate group
discounts on certain office supplies/equipment.
- At first, unless you are buying an existing practice, you could easily lower expenses by
using just one exam room.
- Dont buy things such as specimen containers, culture swabs, biopsy kits, etc. that you
can get from the hospital or lab. They often give you these just for using their services.
Consider using pathology labs that are podiatry friendly, most if not all will give you
supplies for free.

Should I lease or purchase equipment?

Depending on how your accountant has set up your practice, there may be advantages to both
leasing and buying, for example, deducting the lease from your taxes verses writing off the
depreciation after buying the equipment. These types of situations are best discussed with
your accountant on an individual basis.

Its important to keep abreast on matters regarding your business. The new practitioner
should read business journals, join the local small business bureau and take business courses.

Please remember to support the APMSA 2011-2012 Corporate Advisory Board listed on page
10.

258
you think so why buy something that needs replacing so quickly. Used chairs can be
reupholstered easily and cheaply and often come with warranties.
- Buy stainless steel instruments versus chrome plated. Stainless steel will survive better
when autoclaved on a repetitive basis. Quality instrumentation will obviously last
longer and should be sought out when ordering. Also consider obtaining
instrumentation for a surgical pack. When starting ones practice, only two or three
packs would be necessary.
- Depending on finances, dip tanks can be used in lieu of an automatic processor for
developing radiographs. However an automatic processor is preferable despite its
probable cost of around $15,000 (this includes other important instrumentation such as
a Hyfrecator, routine supplies, etc.). Consider digital radiology and digital processing,
this is a more expensive option, however, the technology of the office is moving to
paperless and this may be an expense that is worth it. Not to mention the savings
associated with saving square footage in the office, no dark room, no film storage!
- Buy the bare minimum of office supplies because it is very expensive in the beginning
to keep a lot of inventory that you dont use. Most supplies can be delivered in two to
three days.

What about discounts on supplies and equipment?

- Discounts are available. A 10% discount or more may be negotiated on routine
supplies.
- Prices in catalogs, or the list prices can be anywhere from 40-60% higher than the
actual cost. Send a Pro Forma (which is a list of equipment you are thinking of
purchasing) to the different companies and they will then list the real prices of
everything, so you can get an idea what you will really be paying. Allow competing
companies bid for your business.

Here are some other money saving tips:

- If you move into a community with a large number of podiatrists, investigate group
discounts on certain office supplies/equipment.
- At first, unless you are buying an existing practice, you could easily lower expenses by
using just one exam room.
- Dont buy things such as specimen containers, culture swabs, biopsy kits, etc. that you
can get from the hospital or lab. They often give you these just for using their services.
Consider using pathology labs that are podiatry friendly, most if not all will give you
supplies for free.

Should I lease or purchase equipment?

Depending on how your accountant has set up your practice, there may be advantages to both
leasing and buying, for example, deducting the lease from your taxes verses writing off the
depreciation after buying the equipment. These types of situations are best discussed with
your accountant on an individual basis.

Its important to keep abreast on matters regarding your business. The new practitioner
should read business journals, join the local small business bureau and take business courses.

Please remember to support the APMSA 2011-2012 Corporate Advisory Board listed on page
10.

Its In Our DNA
Langer Biomechanics, Inc. would like to congratulate the class of 2011;
we wish you great success in your upcoming residencies and future endeavors. Langer has
been developing, manufacturing and distributing the highest quality, most innovative lower
extremity products for over 40 years. We are excited to form fruitful and meaningful
partnerships with the promising future of the podiatric community.
Innovation
Quality
Education

Placing your trust in Langer is good for your
patients and good for your practice. Let us show you why.
Call 800-645-5520 today for more information or to
have an Account Specialist contact you.
Biomechanics
261 261
Top Ten Ways to Improve Exam Room Efficiency

1. Place a minimum of two chairs in the exam room for individuals accompanying the
patient to create a consultative environment.

2. Reverse hinge the exam room entry door to create a visual barrier to hallway traffic for
patient privacy.

3. Replace box-style examination table with high efficiency, high-low power tables that are
patient accessible and staff friendly.

4. Place the examination table on an angle to maximize the visualization and lighting
between you and the patient.

5. In consideration of the Americans with Disabilities Act (ADA) Guidelines, exam rooms,
hallways, exits and bathrooms should accommodate wheelchairs.

6. Store diagnostic devices and hazardous waste receptacles to the left of the patient,
making them more accessible to the podiatrist and less accessible to patients.

7. Incorporate a pull-out writing surface into the casework/cabinetry and create an
instant desk when documenting patient records. When not in use, this preserves
valuable floor space.

8. Place sinks in the corner of the room to minimize inadvertent splashes and maintain
cleanliness of countertops.

9. If EMR or computer access is involved, incorporate a desk workstation with a side chair.
This allows the podiatrist to maintain eye contact with their patient during the medical
record taking process.

10. Replace wooden casework with seamless, non-porous casework designed for the
medical environment. Its durability and ease of cleanliness will last the life of your
practice.

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Office Furnishings and Supply Costs

The items listed below are estimations and do not specify companies, brands, or exact prices.

Waiting Room

Chairs (6 seats at $200) $1200
Coat Rack 100
Table(s) 450
Plants 125
Mural/Prints 175
Waste Basket 25
Magazine Subscriptions 25

Private Office for Doctor

Desk, Chair, Mat 700
Bookcase 275
Chairs (2) visitor 300
Waste can 25
Computer 500

Reception Area/Business Office/Nurses Station

Computer and Basic Software $7500
File Cabinets (2) 500
Lateral File 600
Desk, Chair, Mat 700
Waste Can 25
Sound System with Ceiling Speakers 300
Stationary 450
Charts, Stationary 500
Refrigerator 100
Miscellaneous Supplies 250
Copier/Fax/Scanner/Printer (Consider separate Devices) 1500
Card Scanner 100
Consider EMR (Medicare Incentive) 15K -20K

263 263
Medical Equipment for the New Practitioner

The items listed below are suggestions and do not specify companies, brands, or prices.
However, approximately $35,000 is estimated for initial medical equipment cost.

Podiatry chair
Casting table
Instrument cabinet
Doctor's stool (2)
X-ray unit
Exam light
Light handle
Autoclave
Cast cutter, spreader
Stainless steel basin
Mayo stand
Oxygen tank
Tuning fork
Percussion hammer
Ultrasound unit
Electric cautery
Alcohol dispenser
Waste cans (2)
Sani-Grinder (optional)
Heat-blo gun
X-ray processor, film, cassettes (3), film bin, developer, fixer, marker and labels
Darkroom light
View box
Lead apron
Darkroom timer
Lead film blocker
Iodine solution and ointment
Surgical masks and gowns
Sterile surgical and non-sterile examination gloves
Scrub brushes
Autoclave sheets, tape and pouches
Autoclave tape
Sharps containers
Syringes, syringe needles
Surgical blades and handles
Forceps
Nail splitters
Skin hooks
Needle holders
Bone rasps
Hemostats
Bone curettes
Surgical, moleskin, felt, and bandage scissors
Nail nippers and drill
Burs
Dust extractor

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264
Steri-strips
Sterile drapes
Phenol
Antiseptics
Tractograph
Surgical shoes (post-op)
Casting supplies
(plaster, fiberglass)
Cast shoes (Med-Surg Shoes, CAM walkers)
Cast padding
Bandages (Kling, Coban, gauze, Adaptic, Kerlix rolls, 4x4s etc.)
Cotton tipped applicators
Stockinette
Alcohol preps and Skin Preps
Tape (paper, nylon, elastoplast, athletic, etc.)
Band-Aids
Wound Care Supplies (consider 5 major dressing types)
Hand mirrors for patients to observe their feet
Suture
Plastizote
Corex
Cement
Palliative care supplies (moleskin, felt/foam pads, sleeves, etc)
Pre tape
Unna boots
Hemostatic agent
Ammonia ampules
Alcohol
Local anesthetic
Ethyl chloride
Paper towels
Educational board
Utility jars

OTC Items for Resale (Orthotics, Creams, Lotions, Pads)
Miscellaneous- (snacks for diabetic patients, thermometers, glucose measuring devices, blood
pressure cuffs and scales)

Consider going high tech! This route removes all dark room and dark room supplies, digital
radiography saves time and supplies and will pay for itself quickly with efficiency. It removes all
paper goods associated with a charting, EMR software is affordable and with the Medicare
Incentive program over the next 5 years there is no reason not to go paperless.

IX.
Durable
Medical Equipment
and Orthotics
Best wishes and continued success
as you enter the podiatric profession.
On behalf of these generous supporters,
congratulations to the class of 2011.
Advanced Foot Care
Ira Kraus, DPM
Fort Oglethrope, GA
A liated Foot and Ankle Center
Alison DeWaters, DPM
Hal Ornstein, DPM
Howell, NJ
A liates in Foot Care
Peter Paicos, DPM
Lieke Lee, DPM
Stoneham, MA
Terence B. Albright, DPM
North Chicago, IL
Joe Caporusso, DPM
McAllen, TX
Columbia Foot and Ankle Associates
Stephen D. Palmer, DPM
Ross E. Taubman, DPM
Clarksville, MD
R. Dan Davis, DPM
Bridgeport, CT
Chicago, IL
Joy and Glenn Gastwirth, DPM
Potomac, MD
Washington, DC
omas S. Godfryd, DPM
Birmingham, AL
Eric R. Hubbard, DPM, MS.ed.
Long Beach, CA
Mike King, DPM
Fall River, MA
Jay D. Lifshen, DPM
Irving, TX
Nancy L. Parsley, DPM
North Chicago, IL
Marlene Reid, DPM
Westmont, IL
Christian A. Robertozzi, DPM
Newton, NJ
Seth Rubenstein, DPM
Reston, VA
Brian P. Spencer, DPM
Grove City, PA
Frank Spinosa, DPM
Shelter Island, NY
Kathleen Stone, DPM
Glendale, AZ
Phillip E. Ward, DPM
Pinehurst, NC
267 267
Durable Medical Equipment, Prosthetics,
Orthotics, and Supplies (DMEPOS)

Durable medical equipment has become an integral part of podiatric practice. Orthotic devices
lead the way in podiatric DME usage due to our extensive training in biomechanics and diabetic
foot complications. Other DME devices serve in our many treatment protocols to improve care
and increase practice revenue. DMEs are considered an item of medical equipment owned or
rented that is placed in the home to facilitate treatment and/or rehabilitation. DME generally
consists of items that can withstand repeated use and are primarily used to serve a medical
purpose, and are usually not useful to a person in the absence of illness or injury.

Below is a list of DME common to podiatric medicine:

x Ankle Braces
x Walking Boots
x Night Splints
x Extra Depth Shoes/ Therapeutic Shoes
x Heat molded, non custom orthotics
x Custom orthotics
x AFOs
x Some wound dressings

When submitting claims to Medicare for DMEs, be sure you are using your National Provider
Identifier (NPI) number and your name (or the NPI/name of a provider in your group
practice) as the referring/ordering physician for your claim. As new practitioners, you should
already be listed in the Provider Enrollment, Chain, and Ownership System (PECOS)
database because you were enrolled in Medicare after 2003. However, it is still a good idea to
verify you are in the database: https://pecos.cms.hhs.gov/pecos/login.do. You may also
receive warnings/notifications on DME claims if your NPI is not correctly linked to your
Medicare profile or if the spelling of your name (must be in all UPPER case letters) in Box 17 of
the CMS form does not match that of your NPI file.

If you use an outside practitioners NPI number on your claim forms, you are implying that you
are not providing DME for your patients and are serving as a commercial supplier. Due to very
hard work on the part of the APMA, you, as podiatric physicians, are exempt from obtaining a
surety bond or accreditation in order to supply DMEPOS. However, if you use an outside
providers NPI/name you lose this benefit.

In the event that you are unsure whether a DME is covered by a patients particular insurance,
be sure to verify coverage by calling the patients insurance company or advising the patient to
do so. Additionally, a patients insurance may cover a particular DME, but they may owe co-
insurance, a co-pay, or they may not have met their deductible. Knowing this ahead of time
can save you many headaches.

Keep in mind that many HMOs will not reimburse you for DMEs and the patient may need to be
sent to an outside supplier. Additionally, you will probably not be reimbursed for DMEs
dispensed to skilled nursing facility patients and such patients should be given a prescription
for an outside distributer as well. Medicare does not reimburse for all DMEs. In order to bill
the patient for DMEs that are not covered by Medicare, your patient needs to fill out and sign
an Advanced Beneficiary Notice of Non-coverage form (ABN). The latest ABN form can be
found on the CMS website. When an ABN form is used, a GA modifier needs to be included
268
268
with the DME code. Medicaid/Public Aid will not reimburse you for DMEs either, and such
patients should be sent to an outside supplier.

However, do not be discouraged! Many insurers do reimburse for DME and this can be a
profitable part of your practice. As a prescribing practitioner, you should contact your local
insurance carriers, www.cms.gov (Centers for Medicare & Medicaid Services), or
www.APMA.org to verify billing codes, regulations, guidelines and fees relevant to your
geographic area.

269 269
In-Office Dispensing

In-office dispensing is selling products within your office to patients. There are significant
benefits for your patients to have products available in your office. Primarily, that your patient
is saving a considerable amount of time not having to make trips to one or more stores, with
the possibility of the product being out of stock or backordered. This is a value-added service
patients appreciate and compliance is also significantly improved. Patients should read printed
instructions before you dispense and have the product in hand when possible. A professional
can answer questions and explain its use.

Patient satisfaction is improved when consumers perceive your office as one that focuses on
the needs of patients and provides the additional service of in-office dispensing. It is important
in the presentation of these products to make it clear that your patients deserve the best and
that is what you are providing. That being said, make sure you truly believe in the product that
you are selling.

This is also a very profitable source of income. Patients return to your office to re-purchase a
product, keeping your patient population in frequent contact. If a patient is very satisfied with
a product, he/she may refer patients to your office. Not only does your profit margin increase
in this manner, but the constant stream of people in and out of your office can very well lead
to an increased patient population.

How do you begin? Many practices with very successful in-office dispensing programs employ a
technique known as passive marketing. Patients are never told that they have to purchase a
product. Instead a statement is made such as, Mrs. Smith, you really need to use a skin
moisturizer on your feet twice a day. Her response is usually, Can you recommend one for
me? With this response, your door of product opportunity flies wide open.

The idea is to have your patients exposed to various products in several ways throughout your
office. Some offices will have binders available for patients to review information on the
doctors, the staff, the services offered, and a section on foot care products. The section on
products shows what is available and outlines common uses. You can hang a sign in your
waiting room as an added reinforcement stating, We carry several products such as pads,
arch supports, skin moisturizers, ankle supports and healing products in our office for your
convenience.

Many offices have had success with a small display in the reception area showcasing available
products. Try negotiating complimentary display cases from vendors. Patients often ask at the
front desk about which product they should use. Your staff should be trained in non-selling
and instructed not to push a product. Inform the patient that similar products can be found in
the pharmacy, but these are available for purchase in your office if they prefer.

With the advent of digital photography, it is easy to create a collage of your products and have
them enlarged and framed for each treatment room. Patients curiosity as to the use of the
products will lead to increased sales. This also increases patient satisfaction through providing
solutions to their problems. Be sure to let your patients know that they can stop in at anytime
to purchase products.

During follow-up visits, be sure to ask if the products are being used and with the prescribed
frequency. Discuss any improvements noted with use of the product. Offer additional product
if the patient is running low. The key is the soft sell. Convey to your patients that this is not
the focus of their visits, but simply a component of the treatment plan.
270
270

Acceptance of a product is greatly enhanced by relating to a patient how popular the particular
product is among your other patients with similar or identical conditions. Make it clear that if
they want to return the product for any reason, they will be given a full refund without
question. It is rare that a patient will ask for a refund or request a replacement. You should
consider not assigning any time-frame for this offer. If patients come back six months after
obtaining a product, gladly refund their money. Many vendors will issue a replacement product
as well.

When visiting the offices of referring physicians, bring some products that would be appealing
to their staff. Simply let their staff know that you have found these products to be of great
benefit to patients and you would like to provide these gifts for them to try. Again, present the
products simply as part of your treatment plan for the particular condition you are discussing.
The Holidays also provide a prime opportunity for you to assemble a basket of products for the
referring doctor and staff to try.

As mentioned above, do not be fooled by misconceptions regarding patients. They are willing
to spend any money necessary to improve their health. It is your job as the specialist to
inform them of the products that are necessary for their well being. In order to convince your
patients that you know what is in their best interest, you must speak in a manner that is
confident. Your job as a physician is to gain this trust by giving the patient what they need to
feel better and reinforcing the importance of your treatment plan.

Therefore, if you find yourself in a practice rut, consider expanding the service base of your
business. Start by evaluating where you are today. Keep a running list for one month of all of
the patients that you send out of your practice to buy products from others. Go through that
list and decide which of those products you think you could effectively bring into the practice.
Approach it slowly, building one product or service expansion on top another. Each success will
lead to greater confidence and patient satisfaction.

If you decide to dispense, take time examining and using the products available. Ask a few
patients to test them as they are generally willing to provide market research such as skin
moisturizers, keratolytics, antifungal preparations, pain relieving creams/gels, wart therapies
or pre-fabricated orthotics. Visit local pharmacies and supermarkets and explore their foot care
areas to see what is readily available to patients. Pay close attention to podiatric product
advertisements, so you can offer a full array of foot care products.

Pricing is completely up to you. Products can be sold at cost or for profit. If you are selling
products at cost, be sure to factor in your shipping expenses.

Non-covered services such as in-office dispensing should be looked upon as a positive aspect
of the practice. Confidence makes all the difference! Oftentimes, practitioners are non-
definitive with respect to their treatment recommendations. Do not hesitate to offer your
patients a product that will help.
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271
Orthotics in Your Practice

As the health insurance industry in this country continues to change and challenge every
practicing physician, it is important to solidify those services that are unique to podiatry. Many of
our patients who need orthotic therapy must choose to pay out of pocket or go without the
device all together. It is up to each practitioner to provide the necessary information for the
patient to make an educated decision about the proposed orthotic therapy.

100% Satisfaction Guarantee:

As a practitioner, you may consider providing this guarantee to your orthotic therapy patients.
This is especially beneficial for patients for whom insurance does not cover orthotic therapy.
Such a guarantee immediately relieves apprehension about parting with large sum of money.
Rarely will a patient request a refund. More than likely, patients will be more inclined to purchase
the device because there is no financial risk.

Follow Up Visits:

It is important to stress to patients that the orthotics alone cannot treat all their future foot
maladies and they require periodic follow-up exams to assure optimum function of their orthotic
devices. Using the analogy of prescription eyewear that requires eye examination at regular
intervals to disclose any changes in vision can help a patient understand the need for regular
follow up foot examinations to detect any biomechanical changes. Establish a follow up protocol
for your patients. This may include a 3-6 week, 3 month, 6 month, and 1 year follow up.
Consider sending out a letter to all patients 2 years after receiving orthotics to make an
appointment for top cover replacement or orthotic adjustments. Many will respond to this letter
and schedule an appointment.

Second Pair Discount:

Patients often need a second pair of orthotic inserts for their work shoes (heels, boots, dress
shoe, etc). Most orthotic labs offer a discount for additional pairs of orthotics and passing the
savings on to your patients is a great way to provide your patients with biomechanics care
throughout each and every day along with building revenue.

Logo:

Many labs offer the ability to print a customized logo (your office name and number) on the top
covers of the orthotics that you order. This is a marketing strategy that works well when patients
are satisfied with their orthotic devices. Many patients will show their friends their inserts and
those friends will see the logo. This may generate a new patient visit for your practice.

272
272
Getting Started With Orthotics

As an expert in biomechanics, it is essential to provide your patients with quality orthotics that
suitably address pathomechanics and alleviate symptoms. Podiatric physicians are no longer the
only practitioners prescribing orthotics. Generating a superior orthotic protocol will establish you
as the biomechanics/orthotics specialist.

SELECTING AN ORTHOTIC LAB

Quality:

There are many commercial laboratories that produce custom-made orthotics. Competition is
fierce between these labs because they are all bidding for your business. As a new practitioner,
you must make a wise choice in your selection of an orthotic laboratory. The product that you
dispense to your patient is a direct reflection of you. Recognize orthotics as an investment made
by patients to improve their health. Because they are often costly, the patient, and rightfully so,
expects a high quality product. Some orthotic labs excel at producing certain types of orthotics
over others. For example, Lab ABC might produce superior pediatric devices while Lab XYZ
fabricates excellent cork-and-leather devices.

Large vs. Small:

Regardless of the size of the lab, you should receive excellent service. A smaller lab may offer a
limited scope of materials and less orthotic options while a larger lab may offer a larger scope of
therapies and more materials, but this is not always the case. Request catalogues to view
material and device options. As a consumer, you should expect timely turnaround, prompt return
of phone calls, and most importantly, a quality product. This can be achieved in either a small or
large laboratory, as long as the lab is right for you and ultimately right for your patients

Precision and Specificity:

Any lab not compliant with the physicians prescription should be avoided. When a device is not
fabricated to your specifications, it does not reflect poorly on the lab, it reflects poorly on you,
the practitioner, as you dispense the product. Making corrections to orthotics costs you time and
money.

Versatility and Spectrum:

There is no such thing as a standard foot orthotic. Different pathologies require different foot
orthoses. Be sure that your lab can handle several different types of orthoses. If one lab seems
to excel at a certain type of device over others, it might be in your best interest to utilize a few
different labs for your various orthotic needs. Make sure your lab is keeping up with advances in
materials as this may lead to increased efficiency that can be passed on to you and it may
improve the performance and longevity of the device.

Prescription Forms:

You should be comfortable with the components of your labs prescription form. If anything is not
clear to you as to the jargon used, call the lab and ask for an explanation. It is better to
measure twice and cut once! If the lab does not use carbon copies for its prescription forms,
273

273
make a copy of the form to keep in the patients chart. Thus, if there is a discrepancy between
what device you received and what was ordered, you have proof as to what you delineated on
the form.

Pricing:

When choosing an orthotic laboratory, you must consider price and the determination of that
price. Many factors are figured in when a product is priced such as, warranties, adjustments,
delivery time, materials and labor charges. Do not assume that the most expensive or the least
expensive company is going to be the best possible choice. Be sure to do "comparative
shopping." Various accommodations, material changes, top cover lengths and postings are not
always included in the set price of the orthotic and these can add up. Additionally, pre-paid
shipping boxes are not always what they seem and you may be absorbing the shipping cost
elsewhere. Rush deliveries will certainly affect pricing and if you are not happy with the labs
typical turn-around and have to resort to rush services, you should probably select a different
lab.

Warranties:

The lab that you choose should have some form of a warranty policy. Coverage should include
craftsmanship and quality of the material used in the shell, accommodations, posts and top
covers. You as the consumer and prescribing physician should demand that the quality of
craftsmanship and materials last a reasonable amount of time under normal conditions of wear
and tear. If they do not, they should be replaced free of charge or at minimal charge.

Adjustments:

When looking for the proper laboratory, you should try to find one that has a podiatrist on staff
or at least available for consultation. This way you can maximize the use of this lab by making
sure you order the proper orthotic for the pathology you are treating. Many labs will keep
positive casts for a specified period of time in the event that a second orthotic is needed or if the
existing orthotic needs to be sent back for adjustments. Thus, if you need adjustments or a
second orthotic, you do not need to recast the patient. Alternatively, you can request that the
positive cast be sent with the orthotics.

A Good Orthotic Starts With You!

To ensure that your lab receives a good representation of your patients foot in order to start the
fabrication process:
1. Use two splints of plaster of Paris to cast the normal size adult foot and three splints to
cast men's feet over size 12. Do not attempt to save money by skimping on splints as
these casts may not survive the shipping process and can arrive deformed.
2. Allow casts to dry overnight prior to shipping.
3. Ship negative casts in a box with minimal packing material around them and do not ship
negative casts wrapped in plastic lined drapes. Over packing can prevent sufficient drying
needed for the plaster in transit.
4. Do not forget to record the patients name on the cast!

As you begin incorporating orthotics into your budding practice, be sure to make an effort to find
a lab that is best suited to your needs and your patients needs. In conjunction with your own
orthotic protocol, your care in choosing a laboratory with a quality product will ultimately aid in
making your practice flourish.
274
274

Orthotic Tips

1. Communicate with your patient in laymans terms as to how orthotics can help them function
and can alleviate pain. Be specific, but do not confuse your patient with biomechanics jargon.

2. Use illustrations or anatomical models demonstrating how the foot functions with and without
orthotics. Earn your patients trust by taking the time to attempt to educate them about their
gait and mechanics and why orthotics are necessary.

3. Do not promise what you cannot deliver. Be positive about the outcome, but not unrealistic.
Do not place orthotics in a realm of a cure-all treatment. Educate your patient about what
orthotics can and cannot do.

4. Realize that orthoses are not for everyone. Remind your patient (and yourself!) that in
medicine, solutions do not always exist.

5. Treat the patients chief complaint. If another abnormality is not related to his/her chief
complaint, do not treat it. You may create additional problems.

6. Make sure your patients know all of the possible negatives involved in getting into a new pair
of orthotics, such as difficulty in certain shoe gear, possible change in shoe size, the break-in
process, etc. Most patients will be accepting of the downside to many treatments as long as
they have been forewarned.

7. Do not have untrained staff cast your patients for orthotics.

8. Introduce your patient to orthoses slowly. Begin with padding and strapping in order to see
how they respond.

9. Make sure your patients know that orthotics, like eye glasses, only control their problem, and
do not cure it.

10. Be open and honest about the costs involved with orthoses. When it comes to children, take
the time to sit down and discuss future costs with the childs parents. Many physicians offer
replacement orthoses at cost for their pediatric patients.

11. Make sure that the patient is well educated to the use of orthotics. The patient should be
given a set of guidelines for the break-in process, maintenance, and appropriate shoe gear.
This will help ensure the best possible outcome.

275

275
Making the Most of the Medicare
Therapeutic Shoe Program

The Medicare Therapeutic Shoe Program represents a WIN WIN WIN opportunity for patients,
podiatrists as well as Medicare. If qualified patients are correctly fitted with shoes and inserts,
they stand a reduced chance of amputation and infection. Podiatric physicians can significantly
add to their practice because qualified patients are covered for a new pair of shoes with inserts
each year. Follow current Medicare guidelines for application to dispense therapeutic shoes. Visit
www.cms.gov.

The following are suggestions on how to streamline shoe fitting in your office:

One person in charge of orders from start to finish
It works best when one person sees orders through from start to finish. There are many steps in
ordering and dispensing shoes including, the fitting of the shoes, ordering the shoes, obtaining
documentation from the PCP, logging in shoes, contacting patients for pick-ups, billing Medicare,
and returns. If several people are involved, make sure you establish a check-off system for the
process.

Use a fitting set of try-on shoes
Stocking a small number of shoes in select sizes will decrease the guesswork in fittings
associated with using a measuring stick or Brannock device. We all know there can be
discrepancies between sizes among styles and brands. Utilizing a small sizing inventory will
improve fit rates.

Establish an annual system
Medicare covers new shoes and inserts for qualified patients each calendar year. Send patients
reminder letters about the importance of replacing well worn shoes and inserts. Verbiage should
not direct patients to simply come in for a new free pair of shoes. Establish a reminder system
for those patients who return regularly for routine care so as to remind you and the patient that
they are eligible for a new pair of shoes and inserts.

Shoe samples
Nothing works as wells as what you see is what you get. Shoe manufacturers are doing a
better job of creating aesthetically pleasing shoes. Display shoe samples in your waiting room
and be sure to show patients exactly what you are ordering. Some patients who do not qualify
for the Medicare program may be inclined to pay out-of-pocket for shoes.

Advertise
Therapeutic shoe companies can provide you with well designed advertisement layouts that can
be customized to your office. Remember that you should not describe the shoes as free and
you must verify eligibility before guaranteeing Medicare coverage.

Present appropriate shoes
Limit the number of styles you offer to your patients. Choose styles that are appropriate for that
particular patient so as not to overwhelm them with several options, some of which may not be
suitable for their particular pathology. Again, show actual shoe samples to avoid any surprises
when the patient receives her new shoes.

276
276
Know when to use custom shoes
Approximately 10 percent of patients have therapeutic needs that exceed what is possible with
extra depth shoes and are most appropriately addressed with custom molded shoes. Such
conditions include Charcot deformity and partial foot amputations. Either cast these patients for
molded shoes or refer to another podiatrist, pedorthist or orthotist/prosthetist.

Confirm received orders are correct
Your designated shoe staff member should check in all received orders and verify the style, size,
and color. This allows you to send incorrect orders back rather than making this discovery when
the patient is in your office during the fitting.

Return improperly fitted shoes immediately
The whole reason we order shoes for our patients is to ensure a good, proper fit. If the shoe does
not fit the patient, send them back immediately and reorder the proper shoe. Do not allow the
patient to return home with an ill-fitting shoe as this may lead to foot problems and the
manufacturer will likely not take back a used shoe.

Patient education handouts
Go over the shoe break-in process and give the patient written information regarding same.
Have your patients sign an acknowledgement that they received and understood the break-in
process. Dispense the Medicare Supplier Standards for the shoes and document that you have
reviewed these with the patient.

Documentation
PCP Statement, DPM note or prescription, invoice from vendor, copy of signed certificate of
delivery, and acknowledgment of break-in instructions and patient satisfaction.

Make sure the shoes fit before heat molding inserts
Prefabricated inserts can be returned to most shoe companies for a full refund as long as they
are sent back in the condition that they can be dispensed to someone else. Ensure that the shoe
fits before heat-molding the inserts because heat-molded inserts cannot be returned.

Do not write the patients name on the shoe box
Use an adhesive, removable note to record the patients name and stick it to the shoe box. If the
shoes need to be returned, a shoe box with writing on it will have to be replaced and this cost
may be passed on to you.

These suggestions will improve your ability to accurately fit patients and make valuable and easy
use of the Medicare Therapeutic Shoe Program. For additional information visit www.apma.org
or www.cms.hhs.gov/medlearn.

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THE LEADI NG DI STRI BUTOR I N PODI ATRY
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279

Aetrex Worldwide 155
American Academy of Podiatric Practice Management 115
American Association of Colleges of Podiatric Medicine 39
American Board of Multiple Specialties in Podiatry 226
American Board of Podiatric Orthopedics and Primary Podiatric Medicine 20
American Board of Podiatric Surgery 53
American College of Foot & Ankle Orthopedics and Medicine 232
American College of Foot and Ankle Surgeons 54
American Podiatric Medical Association 3
American Podiatric Medical Association Educational Foundation 256
American Podiatric Medical Association Public Education 194
American Podiatric Medical Association Young Members' 22
American Podiatric Medical Students Association Corporate Advisory Board 10
American Public Health Association - APMA Chapter 38
American Society of Podiatric Surgeons 18
Arizona School of Podiatric Medicine 47
ASICS America Corporation 79
Bako Pathology Services 208
Barry University of Graduate Medical Sciences 206
California School of Podiatric Medicine/Samuel Merritt University 134
CrocsRx 277
Darco International 116
Des Moines University 35
Dr. Comfort 231
Florida Podiatric Medical Association 182
Gebauer Company 255
Gill Podiatry Supply Company 24

APMSA 2011 New Practitioners Guide
Index of Advertisers

The APMSA extends its appreciation to its advertisers: corporate, organizational, and
alumnus for their generous support. The APMSA encourages you to support our advertisers
and to utilize the enclosed valuable coupons. Blue companies denote APMSA CAB members.

280

APMSA 2011 New Practitioners Guide
Index of Advertisers

The APMSA extends its appreciation to its advertisers: corporate, organizational, and
alumnus for their generous support. The APMSA encourages you to support our advertisers
and to utilize the enclosed valuable coupons. Blue companies denote APMSA CAB members.

Gordon Labs 14
Histology Associates 57
Hygenic Corporation/Performance Health 26
Langer Biomechanics 259
Merz Pharmaceuticals, Inc. Cover
Moore Medical Corporation 278
New Balance 5
New Jersey Podiatric Medical Association 45
New York College of Podiatric Medicine 225
Officite, LLC 210
Ohio College of Podiatric Medicine 260
Pedinol 117
PICA Group Cover
Present eLearning Systems 52
ProLab Custom Orthotics USA 2
Promet Custom Labs 170
Rockwood Programs, Inc. 118
RX Sorbo Performance Insoles 129
SAS Shoemakers 6
Scholl College of Podiatric Medicine 186
Spenco Medical Corporation 8
Stable Step/Power Step, LLC 185
Straight Arrow Products 207
Swede-O, Inc. 107
Temple University 80
Upsher-Smith Laboratories 157
Western University of Health Sciences 174
Now that you have completed your residency, you are responsible for .
A.) Taking a long, leisurely vacation.
B.) Having a life again.
C.) Making sure you have the proper malpractice
insurance coverage before you see a patient.
Podiatry Insurance Company of America (PICA) was founded by podiatrists, for podiatrists over 30
years ago. PICA is podiatry-focused and the nations top podiatric malpractice insurance provider.
We are endorsed by APMA and offer generous new practitioner discounts. PICA, however, cannot
provide accommodations for a long vacation or assist you with your social calendar.
One Last Quiz
For all of your malpractice insurance needs, visit us online at picagroup.com or call
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1
RITA. Research and Innovative Technology Administration, Bureau of Transportation Statistics.http://
www.transtats.bts.gov/Oneway.asp? Display_Flag=0&Percent_Flag=0. Accessed Aug 24, 2010.
or by calling 1 888 296 1852
Indication
Naftin
(naftine HCl 1%) Cream and Gel are indicated for the topical treatment of tinea
pedis, tinea cruris and tinea corporis caused by Trichophyton rubrum, Trichophyton
mentagro phytes, Epidermophyton occosum and Trichophy ton tonsurans (Gel only).
Naftin
Cream and Gel are contraindicated in individuals who have shown hypersensitivity
to any of their components and are for topical use only. The most commonly reported side
effects of Naftin
are burning/stinging, dryness, redness, itching, and local irritation.

UP TO $100 OFF
*

INSTANTLY FOR ANY
sG0UMP
sG#REAM
sG'EL2XPRODUCT
** Average co-pay shown veried as of August 2010 based
on reports from 380 health plans (eg. HMO, PPO, IPA, etc.)
inclusive of all benet designs/co-pay tiers.
1

Rx ONLY
INDICATIONS AND USAGE: Naftin
Cream, 1% is indicated for the topical

treatment of tinea pedis, tinea cruris, and tinea corporis caused by the organisms
Trichophyton rubrum, Trichophyton mentagrophytes, and Epidermophyton floccosum.
Naftin
Gel, 1% is indicated for the topical treatment of tinea pedis, tinea cruris,
and tinea corporis caused by the organisms Trichophyton rubrum, Trichophyton
mentagrophytes, Trichophyton tonsurans*, Epidermophyton floccosum*.
* Efficacy for this organism in this organ system was studied in fewer than
10 infections.
CONTRAINDICATIONS: Naftin
Cream and Gel, 1% are contraindicated in individuals

who have shown hypersensitivity to any of their components.
WARNINGS: Naftin
Cream and Gel, 1% are for topical use only and not for
ophthalmic use.
PRECAUTIONS: General: Naftin
Cream and Gel, 1%, are for external use only.

If irritation or sensitivity develops with the use of Naftin
Cream or Gel, 1%, treatment

should be discontinued and appropriate therapy instituted. Diagnosis of the disease
should be confirmed either by direct microscopic examination of a mounting of
infected tissue in a solution of potassium hydroxide or by culture on an appropriate
medium.
Information for patients: The patient should be told to:
1. Avoid the use of occlusive dressings or wrappings unless otherwise directed by
the physician.
2. Keep Naftin
Cream and Gel, 1% away from the eyes, nose, mouth and other
mucous membranes.
Carcinogenesis, mutagenesis, impairment of fertility: Long-term studies to
evaluate the carcinogenic potential of Naftin
Cream and Gel, 1% have not been

performed. In vitro and animal studies have not demonstrated any mutagenic effect
or effect on fertility.
Pregnancy: Teratogenic Effects: Pregnancy Category B: Reproduction studies
have been performed in rats and rabbits (via oral administration) at doses 150 times
or more than the topical human dose and have revealed no evidence of impaired
fertility or harm to the fetus due to naftifine. There are, however, no adequate and
well-controlled studies in pregnant women. Because animal reproduction studies are
not always predictive of human response, this drug should be used during pregnancy
only if clearly needed.
Nursing mothers: It is not known whether this drug is excreted in human milk.
Because many drugs are excreted in human milk, caution should be exercised when
Naftin
Cream or Gel,1% are administered to a nursing woman.

Pediatric use: Safety and effectiveness in pediatric patients have not been
established.
ADVERSE REACTIONS: During clinical trials with Naftin
Cream, 1%, the incidence

of adverse reactions was as follows: burning/stinging (6%), dryness (3%), erythema
(2%), itching (2%), local irritation (2%). During clinical trials with Naftin
Gel, 1%,
the incidence of adverse reactions was as follows: burning /stinging (5.0%), itching
(1.0%), erythema (0.5%), rash (0.5%), skin tenderness (0.5%).
GEL CREAM
Manufactured for Merz Pharmaceuticals, Greensboro, NC 27410
2010 Merz Pharmaceuticals Rev 3/10
BRIEF SUMMARY
2 0 1 1
APMSA
NEW
PRACTITIONERS
GUIDE
1
RITA. Research and Innovative Technology Administration, Bureau of Transportation
Statistics.http://www.transtats.bts.gov/Oneway.asp? Display_Flag=0&Percent_Flag=0.
Accessed Aug 24, 2010.
or by calling 1 888 296 1852
Indication
Naftin
(naftine HCl 1%) Cream and Gel are indicated for the topical
treatment of tinea pedis, tinea cruris and tinea corporis caused by Tricho-
phyton rubrum, Trichophyton mentagro phytes, Epidermophyton occosum
and Trichophy ton tonsurans (Gel only).
Naftin
Cream and Gel are contraindicated in individuals who have shown

hypersensitivity to any of their components and are for topical use only.
The most commonly reported side effects of Naftin
are burning/stinging,
dryness, redness, itching, and local irritation.
UP TO $100 OFF
*

INSTANTLY FOR ANY
sG0UMP
sG#REAM
sG'EL2XPRODUCT
** Average co-pay shown veried as of August 2010 based on
reports from 380 health plans (eg. HMO, PPO, IPA, etc.) inclusive
of all benet designs/co-pay tiers.
1

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New Practitioner Kit from DARCO
For 25 years we have been producing innovative products patients love.
Mail or fax this card to 304-781-3887 and receive samples of the DARCO product line
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Visit our NEW website for great offers!
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CongratulationsDoctor!
Name: Email address:
The next step in your professional development is to
join the American College of Foot & Ankle Orthopedics
& Medicine (ACFAOM). Resident Membership is
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And membership for students and residents is free!
Join now by visiting the ASPS Web site at www.aspsfellows.org,
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The American Podiatric Medical Students
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$25 $25
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Fax: ____________________________________________________________________
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American
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ASPS
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Name: ____________________________________________________________,DPM
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2011 Apmsa

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2 0 1 1

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