After over 1,000 hours working on helping patients be reimbursed for medically-necessary, reconstructive liposuction for lipedema I am now working on how much the insurance pays in addition to approving the claim. This is important whether the carrier pays the surgeon or the patient. And yes, always refer to it as medically necessary and reconstructive every time you speak to an insurance representative. It is your mantra.
First, is always expect a denial and be prepared to appeal your liposuction for lipedema claim. And don’t wait as there is a timely-filing period (typically 90 days; more for Medicare). You may have to appeal more than once.
In regard to how much insurance companies pay, the feedback is that it is all over the place. Sometimes it’s less than $300 per procedure, sometimes it’s about $1,200 and sometimes the insurance carrier pays the full amount charged (amounts range between $5,000 and $15,000). We need your feedback so we can determine the best practices to obtain the highest reimbursement possible. Remember, that there is no Medicare fee schedule amount for liposuction, CPT codes 15876-15879 (15879 is the most common, lower extremity).
Some surgeons and patient advocates recommend the unlisted procedure code: 38999. This is simply a matter of preference–both codes have pros and cons. More information on the CPT code debate is in the Guidebook.
Most carriers work off of the Medicare RVU values and their fee schedule. Therefore a carrier can pay any amount they choose. It will be your job to sell the need to pay the entire amount.
I am gathering costs for overhead, personnel, and supplies to help you make your case. In addition, sell the carrier on the fact that it will cost them more to not cover and pay for the service as the condition progresses.
In 2021 I will be working two separate project per my contract so the hours I spend on lipedema is up to you. Please send me feedback on your denials, approvals, and amount. Also include all relevant data such as your surgeon, the insurance carrier and your city and state.
Remember all my information and services are at no cost to you.
Thanks
Jeffrey P. Restuccio, CPC, COC