I receive one to several e-mail messages a day via my web site. Recently, a lady sent the following:
Insurance coverage is definitely an issue in plastic surgery and understandably so; this type of surgery is not cheap. Instead of buying into the idea that every plastic surgeon is some type of money-seeking vacuum cleaner, why don’t we look more deeply into the issue?
Most surgeons (particularly those practicing in Southern California) understand where this kind of discussion might go, but other plastic surgeons understand the true meaning of the word overhead. We have amongst the highest overhead of any sub-specialist surgeons. In order to stay in business, the bottom line must be carefully observed.
Concerning abdominoplasty "The Tummy Tuck," I frequently receive inquiries via my web site concerning insurance coverage. Seeing the points the woman elucidated in the above e-mail message, there may indeed be medical issues involved in this surgery. The case she cites very likely occurred in another state in which insurance reimbursement might not have fallen through the floor yet. There was a time when insurance companies in Southern California paid such claims fairly and without much argument. Still most plastic surgeons I know would not even submit this type of claim for approval. Why Not?
First of all, insurance companies in Southern California thoroughly scrutinize any claims coming from plastic surgeons. While they may initially pre-approve a procedure, at the bottom of all pre-approvals we receive at the office (usually by FAX) is the following statement in bold print:
"This approval does not guarantee payment."
The long and short of this is that after all is said and done, the insurance company is likely to re-consider and not pay for the procedure. That means they don’t pay for the surgeon, the operating facility, the anesthesiologist or the hospital stay. All these bills then arrive in your mail box. An upset patient is by no means a goal in plastic surgery or any other type of medicine. An unpaid bill with an upset patient compounds the discomfort for everybody concerned.
Related to this item is the fact that insurance companies are actively seeking out surgeons that bill fraudulently. This is a criminal offense. Personally, I steer clear of anything that seems even remotely fraudulent when considering billing. This frequently results in a loss of revenue.
Secondly, even if the insurance company did pay the claim, the amount would be paid in an average of three months and the surgeon’s fee (for this procedure) would be about 20% of the amount charged in my office. Insurance companies call the difference between the amount billed and the amount they decide to pay a discount. In Southern California, most insurance plans pay based on Medicare rates. Any surgeon willing to do cosmetic surgery at Medicare rates is very likely not a plastic surgeon. The reimbursement described wouldn’t even pay my overhead for the care rendered.
So when taking the risk and benefit into consideration, abdominoplasty as an insurance case is a loser for the surgeon. I would be suspicious of any surgeon who offered to perform this procedure under insurance coverage. He is taking a huge risk by even billing the case. He may not be paid or worse yet pursued in court by an insurance companies’ lawyer or a federal prosecutor for billing fraud. When the insurance companies’ change their position, I will reconsider mine.