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
Indianapolis, Indiana