Derived from the Greek word “plastikos,” meaning to mold or give form, the specialty of plastic surgery encompasses two general categories:
Reconstructive surgery, which is performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease. It is generally performed to improve function, but may also be done to approximate a normal appearance.
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 (contract) between you and your insurance company, which covers listed procedures. The agreement (contract) for services between you and your plastic surgeon is a different, wholly separate legal arrangement. When you have surgery, you become responsible for payment of the surgeon’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 and/or otherwise not included or expressly stated to be covered by you in your contract with your surgeon.
What is interesting is that reconstructive surgery is generally covered by most health insurance policies, although coverage for specific procedures and levels of coverage may vary greatly. Reconstructive, as stated above, means corrective of some unnatural deformity.
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.
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. For example, 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.
There are three typical cost sharing options:
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.
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.
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.
A woman is planning to undergo hand surgery, the surgical fee will be $2,000. Her plan has a $250 annual deductible, and will cover 80% of her covered medical costs. Because she has paid only $70 so far this year in covered medical expenses, she must pay the first $180 of the covered costs of the hand surgery to satisfy her plan’s $250 deductible. If her plan cost’s share is a percentage-based copayment of 80%-20%, the carrier will pay 80% of the covered costs of the procedure. Once that is settled, she must pay for 20% of the covered costs, plus any costs for which the insurance plan denies coverage.
If the patient’s insurance plan covered the full surgical fee, the cost sharing would look like this:
Reconstructive Hand Surgery: $2,000
Balance of deductible: $180 ($250 – $70) = $1,820
Insurance coverage: $1,820 x 80% = $1,456
Patient payment: $2,000 – $1,456 = $544
The $544 is the patient’s responsibility under the percentage-based copayment arrangement.
A different scenario occurs if the patient has met the deductible and the plan covers the full surgical fee, e.g.:
Reconstructive Hand Surgery: $2,000
Percentage-based agreement: $1,600 (80%)
Patient payment: $400
The patient’s responsibility is, in this example, $400.
If the patient’s insurance has a flat-rate copayment plan for covered medical services with no other limiting conditions and the copayment rate is $15, then the surgical cost might be paid as follows:
Reconstructive Hand Surgery: $2,000
Contracted patient copayment: $15
Balance paid by insurance: $1,985
With a coordination of benefits or dual coverage, the hand surgery patient is also covered under her spouse’s insurance, and the benefits of both plans may be coordinated to cover more of the cost of the surgery. With dual coverage, the patient’s carrier is considered the primary insurer. Coverage under a percentage-based copayment is 80% of the cost of surgery. The secondary insurer, her spouse’s plan, may cover the remaining 20% depending on the specific terms of the spouse’s policy.
After the primary insurer has paid its share, it will send the patient an “explanation of benefits” statement, including the date of service, the doctor’s charges and/or hospital covered charges, the amounts and payment dispersal dates. If the patient is covered under only one plan, she must pay the unpaid balance. With dual coverage, the secondary insurer may pay some or all of the remaining balance. Usually, the secondary insurer will not pay for any portion of the remaining balance until a copy of the primary insurer’s benefits statement is received.
The above illustrate examples of coverage. The amount billed to your insurance by your physician may not be the actual amount on which reimbursement is calculated; your insurance plan may assign a lesser fee for the procedure. Where a physician has agreed to be a contracted provider, these illustrations will not necessarily apply.
Your particular situation will:
Reflect the coverage and cost-sharing agreement of your insurance plan;
The deductible and any amount of the deductible that you have already met;
And any dual coverage available if you are also carried on your spouse’s or another secondary plan.
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.
If you have any genetic deficiencies, which require reconstructive surgery, or have suffered some grave accident, Dr.Fisher is here to help you. Dr.Gregory Fisher of Cerritos Surgery and Laser Center is an expert in reconstructive surgery and has great experience in the field. Please carry your insurance card and find out all about your insurance policy before you visit us.