Plastic surgery insurance: do you read own policy?
Cosmetic surgery is performed to reshape normal structures of the body in order to improve the patient's appearance and self-esteem.
Your insurance policy is an agreement between you and your insurance company. In contrast, an agreement on services and fees is an agreement between you and your plastic surgeon. When you have surgery, you become responsible for payment of the doctor's fees. Coverage for services and levels of payment by your insurance company depend on the terms of the contract between you and your insurance company. You are responsible for any amounts not covered by your plan.
Cosmetic surgery, however, is usually not covered by health insurance because it is elective. Cosmetic surgery is your choice and not considered a medical necessity.
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.
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 flat-rate copayment, reflects a defined share of covered medical costs that the patient pays, with the insurance carrier paying an amount based on the patient's policy. For example, when the patient pays $15 of any office visit charge or $3 for any prescription, the insurance carrier is responsible for the balance.
Your benefits administrator will be able to explain these points to you. Be certain that all patient financial responsibilities are understood before having surgery. If you can calculate your costs based on the terms of your insurance plan, there will be no misunderstanding later of your obligation.
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.
Before beginning this process, carefully read your policy or benefits booklet. Make sure there is nothing in the plan that specifically excludes the type of care you received or are scheduled to receive.
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.
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.
