There are numerous reconstructive procedures that may be covered under your medical insurance program. But plastic surgery is unique amongst medical practitioners in that the insurance companies largely take the position that…anything that involves plastic surgery is unnecessary and cosmetic in nature. While this may not be what their policies say and certainly isn’t their public position, but when you see it from a plastic surgeon’s perspective that statement doesn’t seem too far fetched.

Over the years in my Indianapolis plastic surgery practice, I have faced responses from insurance companies such as…does that child’s cleft lip really need to be repaired ?(medical director of prominent and major health insurance carrier)…there is no need to remove a 30 pound hanging abdominal pannus before knee replacement…burn scar contracture release for better neck motion is a cosmetic procedure. I would like to say that such responses, and hundreds of other seemingly incredulous denials of procedures, is because they did not have sufficient information to make the right judgment. But sadly this is not so. Plastic surgeons are notorious for their photographic documentation and medical detail which is always provided in advance of undergoing any procedure.

Based on our ongoing and continuous unsavory insurance experience, patients need to be aware of several important issues regarding coverage of certain plastic surgery procedures. First and foremost, never call or believe whatever is said to you if you call your health insurance company and ask if a certain procedure is covered. Many patients start off in consultations telling me that their procedures is going to be covered…or I have good insurance and it will cover it. That belief is often dead wrong. At the least, it is ill conceived even if well intentioned. There is a complete disconnect between a customer service agent and the people and process that actually approve a procedure to be covered. This is akin to asking the teller at your local bank if your home loan application would be approved.

Determining whether a plastic surgery procedure is covered under your policy requires what is known as a formal pre-determination. That is a written process and one that takes time, often a minimum of four to six weeks, after a request letter is received. This letter is done by the plastic surgeon’s office and contains the patient’s history, symptoms, medical necessity, diagnosis and procedure codes, and often photographs of the  physical problem. This letter is absolutely necessary because it will generate a written response from the insurance carrier stating whether the procedure is covered or denied. Never proceed to an elective plastic surgery (even if it seems there is no way it could not be considered reconstructive), or allow anyone to take you there, unless you have written confirmation of the procedure approval. Surprisingly, written confirmation does not always guarantee that it will eventually be covered and paid. (seems confusing doesn’t it?) But no written confirmation puts you in financial peril should they refuse payment after the fact…and they have every right to do so since most policies make it clear that pre-determination is a requisite for coverage.

There are exceptions to pre-determination but they are of an acute and urgent nature. If you are in an emergency room or an existing patient in a hospital and develop the need for plastic surgery care, a pre-determination is not necessary beforehand and can be approved after the procedure is done. But for an elective procedure, pre-determination is always needed.

Dr. Barry Eppley

Indianapolis, Indiana

On this week’s Doc Chat Radio show on WXNT 1430AM in Indianapolis from 1:00 - 2:00PM on Saturday afternoon, hosted by Dr. Barry Eppley Indianapolis plastic surgeon,  the controversial topic of Health Care Insurance Reform was discussed. With guest physicians, the pros and cons of the proposed legislation in Washington were covered. Some of the major points of House bill HR 3200 were reviewed and the concerns about a proposed health commissioner and panel for setting national insurance policies were voiced. Issues of patient access, health care financing, and coverage of uninsured and illegal aliens were hot topics of discussion with callers. It was also pointed out that no where in the current health care reform discussions is the important issue of tort or malpractice reform which is conspicuously absent.

Plastic and Cosmetic Surgery consultations with Dr. Eppley can be arranged by calling his Indianapolis suburban area facilities at Clarian North office at  317-814-4100 or his Clarian West office at 317-217-2200.

Patients frequently consult plastic surgeons for procedures and medical conditions that they may feel is or should be covered by their health insurance. Sometimes this is true, other times it is not. Procedures such as breast reduction (female and male), abdominal panniculectomy after weight loss, and rhinoplasty (nose surgery) are common health insurance requests by patients. These are also plastic surgery procedures that are heavily scrutinized by medical insurances and a very specific list of eligibility criteria exist by which they may be deemed medically necessary or of a cosmetic nature. It is not up to the plastic surgeon or the patient to determine if such procedures are covered. That is determined by your health insurance through a process known as pre-determination. This must be done prior to the procedure being performed or it will be automatically rejected even if it otherwise may have been eligible for coverage.

Predetermination by health insurance companies is necessary for selected inpatient and outpatient medical services (including surgeries, major diagnostic procedures and referrals) to determine if they are medically necessary. It is fair to say that all plastic surgery procedures must be predetermined. Health insurances generally assume that if a plastic surgeon is doing the procedure it must be ‘cosmetic’ in nature. This is a process where your plastic surgeon writes a letter to your health insurance company providing them with a diagnosis, any supporting information that proves the problem is causing medical symptoms, and the operations that are needed to fix the medical problem. The key here is that there must exist medical symptoms such as pain, a recurring skin problem, or difficulty with breathing for example. Just because it looks bad or was caused by an accident or birth defect is not enough. (I don’t make the rules, I just have to live by them) Awaiting a response from this letter from your insurance company will take at least 30 days after it has been submitted. It is not a fast process so plan accordingly. Showing up in your plastic surgeon’s office on December 10th for an insurance procedure that you want to do before the end of the year will not work. There simply is not enough time to get it predetermined.

For the member to receive benefits for a plastic surgery procedure, it must be authorized or “precertifed” prior to being rendered. Precertification, often used interchangeably with predetermination, is part two of the process. Precertification can help avoid unnecessary charges or penalties by ensuring that your plastic surgery care is done at an appropriate network facility and by a network provider. Predetermination and Precertication work hand in hand. Precertification is a much more rapid process that can be determined over the phone or by fax between the plastic surgeon’s office and the health insurance company.

Therefore, precertification includes a review of both the service and the setting. Medical care is covered according to the plan’s benefits…not what you think should be covered or how you feel it should be done. Health insurance is basically a business contract not an ethical or moral set of guidelines. Many services will require you to use a provider designated by the health insurance’s list of providers. For benefits to be paid, you must not only be eligible for benefits but the service must be a covered benefit under the contract at the time the surgery is performed.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis

There are numerous plastic surgery procedures that are considered medically necessary, such as breast reduction, breast reconstruction and skin cancer treatments to name just a few. But cosmetic procedures such as tummy tucks, eyelid tucks, or scar revisions are not considered medically necessary even though many patients feel that the insurance company should provide coverage. the issue of potential insurance coverage of a plastic surgery procedure can be sorted out before surgery through a pre-dertemination process or looking at the exclusion clauses in your health insurance policy.

When a medically necessary procedure (plastic surgery or otherwise) is performed at the same time as a cosmetic procedure, however, there is frequent confusion or misunderstandings on the part of many patients. Many patients assume that a ‘portion’ of the cosmetic procedure will be covered since they are asleep anyway and their health insurance is already paying for the operating room expenses and the anesthesiologist’s time. But this perception is wrong….and actually fraudulent in nature.

Your health insurance should and is paying for the time that it takes to pay for the medically part of the operation. Once that portion of the operation is completed, the start and stop times of the procedure are recorded, and the health insurance contributions to the combined procedure are met. Any additional time for the cosmetic portion of the joint procedures is your responsibility. No one will just forget it is going on…particularly the operating room personnel who are scrupulous about recording what operations are done by whom and when. Asking or assuming that the hospital/surgery center will just bill for the total operating time (including the cosmetic portion of the procedure)  to the insurance company will not happen. What you are assuming or asking is known as…fraud. Knowingly billing an insurance company for operations that are not covered under the policy is fraudulent behavior. Which no reputable hospital or surgery center will do and risk significant legal and monetary damages. Any surgeon that would tell you otherwise is either naive or disreputable….either way you place yourself at significant financial exposure. In the end, the hospital or surgery center will bill you…at rates that will be significantly higher than any pre-established cosmetic surgery rates. (often by a factor of 5 to 10 fold)

For these reasons, all of the non-insurance expenses of a combined cosmetic-insurance procedure including the surgeons, operating room, and anesthesiologist time are determined and collected in advance. This is not only the ethical and correct legal thing to do but also puts a known cap on what your cosmetic expenses will be. You never want to expose your personal finances to the non-cosmetic costs (insurance rates) of surgery. 

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis

Third party insurance and potential coverage of surgical procedures is an important part of one’s overall health maintenance program. Many plastic surgeons are happy to participate and aid you in maximizing your insurance benefits. Plastic surgeons work on a daily basis with many insurance providers and are very familiar with this process. It is important that you understand how the process works and the following information is provided to help you in that regard.

Once you are seen and evaluated by your plastic surgeon, and it is determined that your problem may be covered by your health insurance, there is a detailed process which follows to determine your eligibility and benefits available to you through your insurance provider. In most surgical procedures of a non-urgent nature, the proposed surgery must be pre-determined. This consists of a written letter from your plastic surgeon in which will be a description of the medical problem, proposed surgery, photographs, and documentation (if applicable) of symptoms related to the medical problem. No elective plastic surgery procedures today can be approved by a simple phone call.

Please note that plastic surgeons will not submit procedures that are obviously cosmetic nor try to have procedures with a cosmetic intent construed (misrepresented) to be reconstructive. This is considered insurance fraud. Cosmetic procedures are often done with other reconstructive, insurance-covered operations. However, all expenses related to the cosmetic portion of the surgery are the responsibility of the patient and must be paid in advance for that portion of the surgery to be done.

When will my pre-determination letter be sent?

At the minimum, it takes 1 to 2 days to gather all of the medical information and put it in a proper format to be mailed to the insurance company. This time may take longer if there is a wait on supporting documents from other doctors, copies of tests, etc. The final letter will not be sent until all information is obtained. Sending a pre-determination that is incomplete will only result in an immediate denial of coverage and a much longer delay to start the process again.

How long will it take to get a response from my insurance company?

It usually takes from 6 to 8 weeks to get a formal written response from your insurance provider. Typically, you will receive a letter from your insurance company before the plastic surgeon does. Since you are the subscriber, they often will send the determination letter to you and copy the plastic surgeon secondarily as the provider. Therefore, if you haven’t heard anything from the insurance company, your plastic surgeon hasn’t heard either.

If you wish to try and expedite the process, it is important that you contact your insurance provider and notthe plastic surgeon’s office. There is nothing they can do to speed the pre-determination process through the insurance company. Only a subscriber who is paying premiums can move that process forward any faster, if at all.

If you do call your insurance carrier, it is common for them to say that they have not received any materials from your plastic surgeon. This occurs because many insurance providers do not log in any received correspondence for at least 30 days, or until the pre-determination decision has been made. Therefore, if your plastic surgeon says it has been sent and the insurance company say they don’t have it, it is due to the log-in delay.

What if my procedure is denied by the insurance company?

Some plastic surgery procedures, while medically necessary, do unfortunately get denied. In the insurance letter that you receive with that decision are stated the reasons for that denial. Should that happen, your plastic surgeon will work with you to try and get an ultimate favorable decision. Sometimes it only requires additional documentation of the medical condition, but often the denial is based on their determination that it is being done for cosmetic benefit only. On the denial letter is listed the process that you need to do for them to reconsider (appeal). Your plastic surgeon may be able to help you by providing additional documentation but the appeal process is one that is ultimately driven by you-the patient, not your doctor.

 
Dr. Barry Eppley
http://www.eppleyplasticsurgery.com
http://www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis

Breast reduction is a tremendously effective procedure are reducing the size of the breasts and the associated musculoskeletal neck, back and shoulder pains that result from them. Frequently, although not always, breast reduction can be covered by your medical insurance if it is part of their covered benefits.

Whether one qualifies for medical insurance coverage is not a mystery as most insurance companies have very specific criteria to qualify for eligibility. In fact, it is one of the most scrutinized of all plastic surgery procedures covered by insurance. There are several important issues including your weight and breast size, how much tissue the plastic surgeon plans to remove, documentation of painful symptoms, and what other non-surgical treatments have you had.
Your body weight is an important consideration. if you are over 20% of your ideal body weight, your insurance company may say you need to lose weight first. We all know that weight loss will not decrease the size of your breasts (it some cases it may make the skin sag more, causing greater strain on your neck, shoulders, and back), nevertheless, this is a criteria that insurance companies use. At the least, if you are overweight, attempts at weight loss must be done and documented. If you can only lose so much weight, then so be it. But some weight loss effort may be required.

 
The size of your breasts are obviously important. There is no precise breast size that makes the cut-off for insurance coverage. Rather it is a combination of your height, weight, and breast size. Technically, your height and weight are put into a formula to create your BSA. (body surface area) Based on your calculated BSA and the amount of breast tissue your plastic surgeon says will be removed (there is an industry standard graph and table which determines this) is the numerical determinant for medical eligibility. You have no control over what your plastic surgeon estimates will be removed but that number is of critical importance. The whole concept of this numerical determinant is for the insurance company to determine that they are not really paying for a breast lift which is mainly a cosmetic operation. I call this compensation for the ’sins’ of the past done by plastic surgeons from decades ago.

 
One of the hardest criteria to document, but is one of the big three, is what have you done non-surgically that may make your breast and body pain go away without surgery? We all know that nothing short of reducing large breasts will make their symptoms go away, but again, we must play by their rules. Some form of physical therapy, chiropractic treatment, or even acupuncture must usually be tried first (for three months) and documented that it did NOT work. This is the one criteria that many patients do not have when I see them in a breast reduction consult. It may seem like a waste of time and their money, but it usually must be done.

 
As an Indianapolis breast reduction surgeon, I determine possible medical coverage by taking photos and measurements of your breasts and bundle up all of this information listed and send it to your insurance company. The more complete this information is, the less likely you will get a letter (4 to 6 weeks later) that says there is not enough information to make a predetermination. If you meet all of the above criteria, however, there is a good chance your breast reduction may be covered by your health insurance! It can be a slow process, and it may take more than one letter from your plastic surgeon, but persistence and perseverance is the key to a medical necessary breast reduction.

 
Dr. Barry Eppley
http://www.eppleyplasticsurgery.com/
http://www.ologyspa.com/
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis

As the economy continues to tighten, the level of insurance reimbursements from medical procedures continues to get worse. Amidst the presidential campaign banter is the cry for universal health coverage, talked about as if such a system would end up better than what we have now. That is an issue for a different debate, what I prefer to rant about here is the pitiful level of insurance management and reimbursement from all health insurers and the great patient misconceptions about it.
Plastic surgery has always been unique from an insurance perspective in that everything we do has to be pre-determined and pre-authorized by the insurance company to ascertain if there is a medical basis for the procedure. On the surface, I have no problem with that but I have seen a ridiculous number of medical benefits initially determined to be unnecessary including cleft lip and palate repairs in babies, fractured facial bones, breast reconstructions, and reconstruction of skull defects to name just a few.

The pre-determination process, in general, is a 6 to 8 week process which is frustrating for many patients. It usually is much longer as often records are lost or misplaced by the insurer and I have had to send in as many three separate duplicates to get a response. As a result, it can take months to get an answer. And when the patient calls the insurer to find out their pre-determination status, in an effort to move things alone, the insurers are quick to mention that it is the doctor’s office that has failed to respond to their requests for information. This is almost always an outright lie…their system is just so inefficient and disorganized that the right hand has no idea what the left hand is doing. I have seen records mysteriously appear after they ‘couldn’t find them for months’.
Once a response to the claim is returned, it will often be that the pre-determination has been denied due to insufficient information. (of which we had already sent them this information numerous times!) There is obviously a great black hole at their offices where all this redundant information must go. Then if the pre-determination is approved, there is also the written caveat that comes with it that the an approved procedure doesn’t guarantee that payment for services will be made. So they will approve it but an approval has nothing to do with payment. Isn’t that why we went through the pre-determination process in the first place?
The real entertainment begins when a bill is submitted for services rendered to the insurer? I have never seen so many imaginative ways that payment can be delayed or denied. From we don’t know who this member (not in our active insureds), we have no predetermination on this member for this procedure (even though they did pre-determine it), to one of the hundreds of numbers on the claim submission form is missing, few surgery payments ever get paid in a remotely timely manner.

Always remember doctors get paid last. Then when the payment comes 3 to 9 months later after numerous man hours of paperwork efforts and phone calls, the reimbursement rate will be anywhere from 8 to 12% of what was charged. With an often noted commentary on the paid bill to the patient that ‘your doctor charges were above the usual and customary rate’ for this procedure. A veiled attempt to make the doctor look like they were fraudulent in their charges. Contracted rates by health insurers are universally horrendous but who is it that creates this reimbursement rate? Patients are under the misconception that the doctors have negotiated these rates. Quite the contrary, contracted rates mean if you want to sign up, here is what you are going to get…period. There is no true discussion or negotiation. While it is true that signing up for any insurance plan on the physicians part is voluntary, but for most doctors who only do insured patient services, what other option do you have.
Fortunately, as a plastic surgeon, only about 15% of my practice now is insurance. But I have a hard time seeing how any further socialization of the health care system is going to improve the doctor’s experience of it…….And, by the way, if you want to speed up payments from the insurers, you can now sign up for electronic claim submission. Indeed it may be faster…but the fine print is that it costs thousands of dollars to become registered and there will be a hefty monthly hosting fee for your practice.
Dr Barry Eppley
Indianapolis

Medical Insurance and Plastic Surgery – Will my health insurance cover my plastic surgery?

Many plastic surgery procedures may be eligible for coverage by your medical insurance, provided that they are done for reconstructive purposes. Procedures performed for changes in face and body appearance only are viewed as cosmetic and not covered by insurance. To avoid postoperative confusion and potential economic hardship, every plastic surgery procedure that your plastic surgeon judges to be eligible for insurance coverage must go through a pre-determination process to ascertain whether insurance coverage is available to you. This involves a written letter, complete with photogtrtaphs of the problem, and will take an average of 6 to 8 weeks to get a written response back from your health insurance company.

To qualify for reconstructive plastic surgery, there must be some bodily function that is going to be improved by the operation. Appearance is not generally considered reconstructive unless it is from a congenital birth defect or accidental injury.

The following are some examples of reconstructive surgery and the symptoms that they might improve:

Breast Reduction…….back, shoulder, and neck pain

Abdominal panniculectomy……eliminate chronic skin infections

Skin graft…….heal an open wound

The following are some examples of plastic surgery that are considered cosmetic and not covered by insurance:

Rhinoplasty
Abdominoplasty
Facelift
Liposuction
Breast lift
Arm Lift

Dr Barry Eppley
http://www.eppleyplasticsurgery.com/
http://www.ologyspa.com/
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis