Plastic surgery: what's covered
As you plan for plastic surgery, you will probably learn a lot about what will happen in the operating room and discuss with your plastic surgeon how you will look and feel afterward. However, another important part of being an informed patient is knowing about the costs associated with plastic surgery, and how these costs will be paid.
Your insurance policy is an agreement between you and your insurance company. In contrast, an agreement on services and fees is an agreement between you and your plastic surgeon. When you have surgery, you become responsible for payment of the doctor's fees. Coverage for services and levels of payment by your insurance company depend on the terms of the contract between you and your insurance company. You are responsible for any amounts not covered by your plan.
Reconstructive surgery is generally covered by most health insurance policies, although coverage for specific procedures and levels of coverage may vary greatly.
There are a number of "gray areas" in coverage for plastic surgery that sometimes require special consideration by an insurance carrier. These areas usually involve surgical operations which may be reconstructive or cosmetic, depending on each patient's situation.
Example of "gray areas" in coverage is eyelid surgery (blepharoplasty) - a procedure normally performed to achieve cosmetic improvement - may be covered if the eyelids are drooping severely and obscuring a patient's vision. Or, nose surgery (rhinoplasty and/or septoplasty) may be covered if it will correct a defect that causes breathing difficulties.
In assessing whether the procedure will be covered by the patient's insurance contract, the carrier looks at the primary reason the procedure is being performed: is it for relief of symptoms or for cosmetic improvement? If a procedure is within these "gray areas," insurance companies often require prior authorization or approval before the surgery is performed and/or extra documentation after surgery to determine how much of the cost of your care they will cover.
It's important to understand what's included in your policy before you advance too far in planning surgery. Some policies provide coverage for many plastic surgery procedures while others are more limited in coverage. Read your policy and benefits manual carefully and discuss any questions you may have with your insurance plan manager.
Typical cost sharing option maybe a flat-rate copayment, reflects a defined share of covered medical costs that the patient pays, with the insurance carrier paying an amount based on the patient's policy. For example, when the patient pays $15 of any office visit charge or $3 for any prescription, the insurance carrier is responsible for the balance.
Typical cost sharing option maybe a percentage-based copayment, reflects a percentage share of covered medical costs that the patient pays, with the insurance company paying an amount based on the patient's policy. Examples are: 20% of the office visit charge - $10 of a $50 charge, $12 of a $60 charge, etc. Typically, this copayment arrangement includes a deductible and may have other variations.
Your benefits administrator will be able to explain these points to you. Be certain that all patient financial responsibilities are understood before having surgery. If you can calculate your costs based on the terms of your insurance plan, there will be no misunderstanding later of your obligation.
The amount billed to your insurance by your physician may not be the actual amount on which reimbursement is calculated; your insurance plan may assign a lesser fee for the procedure. Your particular situation will reflect the coverage and cost-sharing agreement of your insurance plan; the deductible and any amount of the deductible that you have already met; and any dual coverage available if you are also carried on your spouse's or another secondary plan.
Once you and your plastic surgeon have agreed on the specifics of your care and the fees, it's likely that your plastic surgeon will assist in determining if your care is indeed covered by your insurance plan. Your plastic surgeon will probably send a pre-authorization letter to your insurance carrier, explaining the procedure, listing the ICD-9 (diagnosis) and CPT (procedure) codes, the surgical fee, place of service, and anesthesia. The pre-authorization letter will request authorization to proceed with your surgery and an indication of the level of coverage provided by your policy. Before giving the "go-ahead" to proceed with surgery, the insurance company will review your case to ensure that the procedure is medically necessary based on the insurance carrier's guidelines of medical necessity.
If your insurance company does not authorize payment for your reconstructive surgery, or if it agrees to pay only a small percentage of a claim, you may choose to appeal the decision.
Before beginning this process, carefully read your policy or benefits booklet. Make sure there is nothing in the plan that specifically excludes the type of care you received or are scheduled to receive.
Your appeal letter should also request a full explanation of why coverage is being denied or paid at a reduced level. Request that the claims supervisor send you a copy of the specific statement - drawn from the policy or from the benefits booklet - that explains why your coverage is limited or denied. Attach a copy of the denial notification and a copy of your doctor's pre-authorization letter to again provide the statement of your surgeon's fee, the applicable billing codes. Position papers are available from your plastic surgeon.
