Plastic surgery and your insurance company
Cosmetic surgery is performed to reshape normal structures of the body in order to improve the patient's appearance and self-esteem.
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 deductible, is the total amount of covered medical expenses that must be paid by the patient before the insurance company begins paying benefits. Examples of standard deductibles are $100, $250, or $500. After this requirement is reached, the insurer will begin paying according to terms of the contract-often 75%-85% - of covered medical costs. The patient is responsible for any remaining 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.
Understanding your policy and your responsibility for payment is essential. Securing approval of medical services and fees by your insurance carrier prior to surgery will prevent any misunderstanding of coverage and responsibility for payment after your care is complete.
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.
During this review period, make sure you have a clear understanding of the costs and fees, and determine the portion you'll be expected to pay. Remember, if a hospital stay is also required, a number of other costs will be involved.
Keep accurate notes of all communication with the insurance company and your plastic surgeon, and make a personal file to keep copies of completed insurance forms and every letter sent or received. Keep your file in a safe place in case papers are lost in the insurance process or the mail or you need to reference anything about your surgery.
In appealing the decision, your first step is to write a letter to the insurance company representative (usually the claims supervisor) who signed the notification of denial. In the letter, explain why you feel the procedure should be covered and ask that your request be reviewed by a certified plastic surgeon.
Your plastic surgeon practices in an ethical manner and will submit claims to insurance carriers only for valid reconstructive plastic surgery. Any attempt to misrepresent a cosmetic procedure as reconstructive is unethical. Cosmetic procedures are elective, and payment is the responsibility of the patient.
Some plastic surgeons accept major credit cards or offer financing programs that allow patients to make manageable monthly payments for cosmetic surgery. Ask your surgeon's office staff if any such programs are available.
