ST. LOUIS (KMOX) – The American Orthotic and Prosthetic Association sued the U.S. Department of Health and Human Services last month claiming new rules that require clients to get physician documentation that a prosthetic is necessary are unreasonable.
Part of the suit focuses on the burden placed on suppliers like Catherine Burns, owner of Ann’s Bra Shop, when physicians fail to provide proper documentation. Burns says 40 percent of her business is for prosthesis for women who’ve had their breasts removed.
The rules now require clients of Burns to get documentation from their doctor stating that the prosthetic is needed. Burns says board-certified businesses like hers used to do this but the new rules are being applied retroactively by a subcontractor that Burns says is being paid based on their rate of denial.
“Going retroactive affects our cash flow,” Burns says. “Going forward, we want the ability as board-certified professionals to be able to make that assessment.”
Burns says she’s had 20 claims worth $10,000 denied and while she’s appealing them, she says it’s unlikely she’ll get those prosthetics back.
The new rules don’t make sense to ask surgeons who’ve removed body parts to now know what type of prosthetic is needed, Burns adds.
“That’s their specialty,” she says. “The next process for that patient then is to go to a professional that would provide a prosthesis, an arm, a leg, a breast, whatever it may be.”