Medical Insurance, Pre-Determination and Plastic Surgery

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 e 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 not the 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 is a board-cer

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