My prosthetist told me that my doctor will not give any notes for my prosthesis and they cannot finish it for insurance reasons. What are my legal options?

13 Apr 2017

Dealing with doctors, insurance companies, and medical suppliers can be very frustrating for amputees. There is a big problem with insurance coverage and prostheses, which can lead to problems for the patient. The problem began in 2011, when Medicare issued a letter to doctors which outlined the documentation requirements that must be documented by the doctor for the prosthetic limb to be covered under Medicare. If a doctor’s medical records, prescription, prothestist’s notes, treatment plan, and the prosthetic delivery do not match, Medicare will likely refuse payment to the prosthetist.

Unfortunately, doctors are not prosthetists and do not understand the nuances of what must be written in the prescription. Generally, the prescription must demonstrate that the prosthetic arm or leg was reasonable and necessary.

If there is an audit, Medicare may request medical records for patients from the prosthetists. The prosthetic clinic must have the medical records showing the patient’s current functional capabilities and the expected functional potential. The prosthetic clinic is responsible for providing the correct documentation from the doctor. If the clinic does not have the notes, the clinic may refuse to give you the prosthetic until getting the proper notes, or give you a less-expensive prosthetic, which could take less justification, or provide the service to you anyway and hope there is no audit.

If you are an amputee and you are stuck in a battle with your insurance company, call me, Amputation Attorney Conal Doyle at 310-385-0567. I am also an amputee, and I enjoy helping other amputees fight insurance companies that are acting in bad faith. Call today to learn more.