Along with the many physical and financial trials that breast cancer may impose on a patient’s life, the worry of having to pay for reconstructive surgery after treatment presents a challenge to many. Many breast cancer survivors bypass reconstruction surgery out of fear that they won’t be able to cover the full cost of the procedure.
Fortunately, thanks to a law passed in 1998, health insurance carriers that cover expenses for a mastectomy or lumpectomy must also cover expenses for reconstructive procedures to restore the patient’s physical and mental well-being following cancer surgery.
Renowned plastic surgeon Dr. Olga Bachilo performs reconstructive procedures for patients in the greater Houston area and neighboring communities such as Sugar Land and Katy at Glamour Plastic Surgery and Med Spa, where most major health insurance plans are accepted and provide for coverage of qualifying procedures.
What is the Law regarding insurance coverage for breast reconstruction procedures following mastectomy?
The fear of having to pay out of pocket for reconstructive procedures was based on insurance mandates that were in place as recently as 1998, when health insurance carriers classified breast reconstruction following mastectomy as a cosmetic procedure and deemed these procedures as not being medically necessary. Many insurers rejected claims on this basis, and many breast cancer survivors were left with a dramatically altered physical appearance because they simply could not afford plastic surgery following the challenges of dealing with breast cancer.
The passage of the Women’s Health and Cancer Rights Act in Congress in 1998 finally changed that. The bill’s Congressional sponsors and defenders made the point that reconstructive surgery after a mastectomy was a necessary treatment to improve the physical and psychological outlook and quality of life for many patients.The Women’s Health and Cancer Rights Act of 1998 requires that all group health insurance plans that cover mastectomy must also cover prostheses and reconstructive procedures.
Today, if your health insurance policy covers mastectomy or lumpectomy – as most major carriers should – it should also cover breast reconstruction procedures as part of breast cancer treatment. This coverage must apply whether you choose to have reconstruction done immediately or soon after the mastectomy or lumpectomy, or whether you decide to have the reconstruction many years later. Coverage should also extend to revisionary procedures that may be required over the course of time to correct or revise the reconstruction, such as procedures performed to achieve symmetry and balance between the two breasts.
How do I know if my insurance plan covers breast reconstruction?
It’s always best to contact your health insurance provider directly before making any medical appointments to check on what exactly is covered by your policy. This helps you plan ahead and avoid the hassle of requesting payment for procedures later on.
You can also check with your state’s Health Insurance Agency and Commissioner to inform yourself of all laws that require coverage for breast reconstruction and what exactly is covered by law in your state.
Medicare covers breast reconstruction procedures, although Medicaid coverage may vary by state. Government-sponsored plans as well as those provided by churches or religious institutions may be exempt from the 1998 Act, and therefore may not be required to cover breast reconstruction. Check with your plan administrator to find out whether you are covered for these procedures or not.
Our office staff at Glamour Plastic Surgery and Med Spa is also very familiar with the process of handling insurance claims and will be happy to help you determine whether you will be covered for reconstructive procedures performed by Dr.Bachilo.
Will insurance cover all the costs of the procedure?
In her book The Breast Reconstruction Guidebook, author Kathy Steligo advises that you have a thorough discussion with your insurance carrier and provides a list of questions to ask when discussing coverage for breast reconstruction after cancer treatment.
Among the questions that you should ask, make sure to inquire as to any limits that may apply to the coverage provided. For example, ask if your hospital stay will be covered in addition to the cost of the procedure itself. If so, ask how many days of coverage is provided. Also ask whether the fees of other medical personnel involved in the process of providing your reconstructive treatment will be covered. Also find out whether payments will be made directly to the providers or if you will be responsible for paying the medical bills with reimbursement.
With most insurance carriers, all costs are not fully covered and patients are responsible for deductibles and co-pays, so you must be fully aware of how much your co-payments are for each visit or treatment, and how much is your deductible so you can plan in advance for what you’ll be paying out of pocket.
If you find that you must pay out of pocket for a portion of the treatment, it may influence your decision regarding the type of reconstruction you can afford to undergo. While costs may vary widely as each patient is unique and each procedure requires different considerations, implant procedures typically are less expensive than flap surgery and fat transfer procedures. But implants are the most likely to require future revision procedures, so the expenses may be comparable over time.
Can my insurance carrier refuse to cover any costs?
Even with coverage, there may be certain situations in which your carrier may refuse to cover certain costs. For example, if you opt for a newer type of procedure to create a more balanced and symmetrical appearance between the breasts, or if you need a full revision of a past reconstruction, it must be very aptly stated that these procedures are not being performed exclusively for cosmetic reasons. Your coverage may also refuse to cover a plastic surgeon outside of your plan’s network.
According to Dr. Frank J. DellaCroce, plastic surgeon and co-founder of the Center for Restorative Breast Surgery, it is extremely important that your plastic surgeon’s office communicate correctly with the insurance company about your surgery, as that can make a major difference in how the carrier handles the claim. The surgeon must clearly indicate that the procedure is medically necessary and not purely cosmetic.
Your surgeon’s office must also use the appropriate language as specified in the ICD code, a standardized classification system used by all insurance carriers.
What can I do if coverage is denied?
If coverage is denied, it pays to be persistent and appeal the carrier’s decision. Your surgeon can revise the description of the procedure and resubmit, and the office may send photographs to further illustrate the problem and defend the doctor’s diagnosis.
You should be sure to print out all correspondence and maintain full records of every step in the interaction with your insurance company as you pursue your case.
Chapter 19 of The Breast Reconstruction Guidebook features detailed information about how to appeal your insurance carrier’s denial of coverage, with excellent tips about how to effectively go through the entire process.
If you’d like to learn more about your rights to coverage under the Women’s Health and Cancer Rights Act, visit the American Cancer Society’s Women’s Health and Cancer Rights Act page, where they provide a FAQ page that provides great information.
For additional information regarding insurance coverage for breast reconstruction procedures, contact our friendly and knowledgeable staff at Glamour Plastic Surgery and Med Spa.
Glamour Plastic Surgery and Med Spa, Olga Bachilo, MD, 6300 West Loop South, Suite 620, Bellaire Texas 77401, 713.766.4428, hello@glamourplasticsurgery.com, GlamourPlasticSurgery.com
Name: Olga Bachilo, MD
Title: Plastic Surgeon and owner
Company: Glamour Plastic Surgery and Med Spa
Location: Houston, TX
Email: hello@glamourplasticsurgery.com
Website: http://www.GlamourPlasticSurgery.com
Phone: 713-766-4643
LinkedIn:https://www.linkedin.com/in/olga-bachilo-48774091/
Instagram:https://www.instagram.com/glamourplasticsurgery/
Facebook: https://www.facebook.com/GlamourPlasticSurgery
Twitter:https://twitter.com/GlamourPSMS
Bio:
Dr. Olga Bachilo is a female Plastic Surgeon who specializes in cosmetic and reconstructive procedures of the breast, body and face. Committed to treating each patient with integrity and compassion, her unique combination of competencies are sought after throughout the community. She also performs an assortment of non-surgical and minimally invasive procedures in her medical spa.
Originally from Minsk, Belarus, Dr. Bachilo moved to Houston, Texas with her family in 1998. She attended the prestigious Rice University in Houston, TX completing her undergraduate degree with majors in Bioengineering and Biochemistry. Dr. Bachilo obtained her medical degree at the Texas A&M Health Science Center College of Medicine in College Station, TX and Temple, TX, and then completed an integrated Plastic Surgery residency at University of Texas Medical Branch in Galveston, TX.
You are my inspiration , I own few web logs and rarely run out from to brand : (.