Althea's footwear the footwear place Lazy employees Everett Washington

Monday, April 06, 2015

As the Operations Manager of Althea’s Footwear Solution, Inc. (Everett) & The Footwear Place (Lakewood) – I would like to respond to the report filed by Mr. X.

“Harold” is not his real name and he does not live in Middletown Connecticut. Although I know his identity, because of the Attorney General’s complaint he filed, I will respect his wishes, keep his identity secret and refer to him as Mr. X

To the casual observer, our business may look like just another shoe store. However, it is that and much more. Our business is certified by the American Board for Certification in Orthotics, Prosthetics and Pedorthics, Inc. and we have nine highly qualified Pedorthists, also all of whom are certified by the American Board for Certification in Orthotics, Prosthetics and Pedorthics, Inc.

These professionals went through an extensive course of study and examination to become certified and they maintain their certifications by taking continuing education courses as are required by all credible professional certifications.

As mentioned above, we are more than a shoe store. The vast majority of our business is taking care of patients that have a vast array of foot problems, one of which is the special needs of the diabetic community. In doing this, a majority of our patients are covered by either private insurance or Medicare.

In the case of a diabetic covered by Medicare, as is Mr. X, we have specific, rigid requirements that must be met before we have any chance that the claim will be paid for by Medicare. We have forms, governed by Medicare, that must be filled out by the patient and information that must be requested from his doctor. We need three things to submit a legal and valid Medicare claim: a prescription with a diagnosis that is covered by Medicare, a Certificate of Medical Necessity signed by the patient’s doctor and the patient’s chart notes supplied by their doctor. We can help facilitate obtaining this information, but are limited to only making requests. We can’t change a doctor’s diagnosis or force them to send the chart notes. We can’t submit false information without risking denial of the claim, fines and/or jail time for insurance fraud.

In Mr. X’s case, here is a timeline, taken from our chart on Mr. X, of what really happened:

• 12/9/2014 – Mr. X came in as a new patient with a prescription from his doctor for diabetic shoes, which is only one of three things needed to complete a valid and legal claim with Medicare. Despite only having one third of the required documentation, we agreed to perform our evaluation under the condition he would see his doctor for the missing paperwork. He was evaluated and, given the Medicare governed forms and told we also needed a signed Certificate of Medical Necessity and the chart notes from his doctor in order for us to proceed with a Medicare claim. We are restricted by the Health Insurance Portability and Accountability Act (more commonly known as HIPAA or HIPPA) to the type of information we can obtain directly. We can request certain information but the patient is in control of giving permission and the doctor is in control of when and if they send the information. From our side, we can’t force the doctor to actually send anything, all we can do is send a request.

• 3/3/2015 – After being advised of the information required and given the correct Medicare governed form, Mr. X waited almost three months to see his doctor again (on this date) and get a Certificate of Medical Necessity and a new prescription, both of which were faxed to us after his doctor’s visit. However the chart notes were not sent. As mentioned above, all three are required in order for us to file a legal and valid claim with Medicare. Within minutes of receiving the Certificate of Medical Necessity and the prescription, we sent a FAX to Mr. X’s doctor requesting the chart notes.

• 3/10/2015 – Not having received the chart notes, we again sent a FAX request for them to Mr. X’s doctor. Sometime after this date but not received by us until 3/19/2015, Mr. X’s doctor sent the chart notes via U.S. Mail.

• 3/13/2015 – Mr. X called frustrated that it was taking so long to get the chart notes. We suggested he call his doctor and apply some pressure from his side since the doctor was ignoring our requests. We have found that, historically, this is often effective at getting the doctor to send the notes.

• 3/16/2015 – Mr. X filed a complaint with the Washington Attorney General’s Office about this matter.

• 3/19/2015 – After receiving and reviewing the chart notes (on this date) from Mr. X’s doctor, (and before any knowledge of a complaint to the Attorney General’s Office or the Rip-Off Report) we found the supporting documentation would not meet Medicare’s qualifications for coverage, leaving Mr. X responsible for paying for our services. We therefore sent Mr. X a denial letter with a detailed reason as to why the claim would not be supported and sent suggestions on how to clear up those items with his Doctor.

  We are prevented by the Health Insurance Portability and Accountability Act from including the doctor’s exact diagnosis in this post, but Mr. X could post it.

  As for our lazy employees, not one of them is lazy. If any of them were lazy or not totally dedicated to the welfare of our patients, they would not be here. If anyone wonders about that, I invite you to come in and observe them for an hour. They all work tirelessly to service our patients to the limits of their certifications and within the law.

   

  If you have any questions that would help fill in any gaps I may have left, please contact me. I have included my real name and personal email below.

   

  Jim Schmoker

  Operations Manager

  Althea’s Footwear Solutions and The Footwear Place

  Smoky@Geminico.com