Global Courant
Patients often consult plastic surgeons for procedures and medical conditions that they feel are or should be covered by their health insurance. Sometimes this is true, other times not. Procedures such as breast reduction (female and male), abdominal panniculectomy after weight loss, and rhinoplasty (nose surgery) are common requests from patients to health insurance. These are also plastic surgery procedures that are heavily controlled by medical insurance and there is a very specific list of eligibility criteria by which they can be deemed medically necessary or of a cosmetic nature. It is not for the plastic surgeon or the patient to determine whether such procedures are covered. That is determined by your health insurance through a process known as predetermination. This must be done before the procedure is performed or it will be automatically rejected, even if it would otherwise qualify for coverage.
Advance determination by health insurers is necessary for selected inpatient and outpatient medical services (including surgeries, major diagnostic procedures, and referrals) to determine whether they are medically necessary. It is fair to say that all plastic surgery procedures should be predetermined. Health insurance generally assumes that if a plastic surgeon performs the procedure, it must be ‘cosmetic’ in nature. This is a process where your plastic surgeon writes a letter to your health care provider with a diagnosis, all supporting information proving that the problem is causing medical symptoms, and the surgeries needed to correct the medical problem. The key here is that there must be medical symptoms, such as pain, a recurring skin problem, or difficulty breathing, for example. Just because it looks bad or was caused by an accident or a birth defect is not enough. (I don’t make the rules, I just have to live by them) Waiting for a response of this letter from your insurance company will take at least 30 days after it is submitted. It’s not a quick process, so plan accordingly. Showing up at your plastic surgeon’s office on December 10 for an insurance procedure you want to do before the end of the year won’t work. There simply isn’t enough time to get it predetermined.
To receive benefits for a plastic surgery procedure, the member must be authorized or “pre-certified” before being granted. Pre-certification, often used interchangeably with pre-determination, is part two of the process. Pre-certification can help avoid unnecessary costs or fines by ensuring that your plastic surgery care is performed in an appropriate in-network facility and by an in-network provider. Predetermination and Precertification go hand in hand. Pre-certification is a much faster process that can be determined by phone or fax between the plastic surgeon’s office and the health insurance provider.
Therefore, pre-certification includes an assessment of both the service and the institution. Medical care is covered according to the benefits of the plan…not what you think should be covered or how you think it should be done. Health insurance is essentially a business contract, not an ethical or moral set of guidelines. Many services require you to use a provider designated by the list of health insurance providers. In order to pay benefits, you must not only be eligible for benefits, but the service must also be covered by the contract at the time the operation is performed.
Plastic Surgery Insurance Provision
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