Below are some common questions we get concerning reimbursement for medically necessary, reconstructive liposuction for lipedema.
www.LipoForLipedemaReimbursement.com will help you get covered for out-of-network gap coverage.
What does this mean? It means that all physicians must be contracted with an insurance company to be considered “in-network.” Most all doctors are contracted with Medicare (but not all). Private insurers will have doctors in your area either “in-network” (contracted) or “out-of-network” (not contracted).
The problem with liposuction surgeons is that since most of their work is cosmetic they may not be contracted with any healthcare insurance carriers. None.
Plus their staff may have little experience working with medical billing and insurance carriers which takes hundreds of hours (thousands…) and years of experience to learn all the ropes.
In 2021 more liposuction for lipedema surgeons are signing on with insurance carriers as “in-network” and more are helping patients submit the claims for reimbursement and cooperating with Single Case Agreements (SCA’s). Some surgeons are much more “insurance-friendly” than others.
Q: Is a Functional Assessment necessary?
Your lipedema specialist should document your functional limitations in the medical record. This is not one specific test but specific scales and measurements to quantify the patient’s ability to perform Activities of Daily Living (ADL). Improving functionality is a component of reconstructive surgery; therefore the more detailed, organized and qualitative the analysis—and the greater the disability outlined—the better the argument for reimbursement.
With that being said, documenting or reporting anything not clinically accurate just to be paid is considered fraud and the penalties can be severe. Some physicians charge an additional fee for this diagnostic survey. It is not something found in the research literature either way (recommended or not) and most lipedema specialists can accurately document Quality of Life and compromised functionality issues in their standard assessment (exam and history).
Click on this link for more detail on specific functionality components.
Q: What Supporting Documents Do I Need?
This is all outlined in the Checklist and explained in more detail in the free Guidebook.
Q: What Is Fair And Reasonable Payment?
In regard to a fair and reasonable payment you will see three general scenarios:
Approval but very poor payment of less than $300 per procedure.
Approval and reimbursement in the $1,200 range which is a median amount for comparable integumentary system procedures. The issue here is that liposuction for lipedema is much more time-consuming and labor intensive than most comparable integumentary system procedures.
Reimbursement close to what was charged by the surgeon. This is ideal and while I don’t have actual statistics I would think that it’s less than 30% of the cases. In other words, I have no incentive and would not want to inflate your expectations that the norm is full coverage. See relative RVU’s just to see how other procedures are paid.
Q: Do I Need Prior-Authorization?
Always strive to get a prior authorization from the insurance company for your procedure. If your surgeon is out-of-network you will need to get a Single Case Agreement (SCA) which needs to be negotiated with the surgeon’s office. Always contact the insurance company and file the claim before the procedure is performed—even if you don’t have all your information. It is a lot more difficult to get them to respond after the procedure is done.
Always expect at least one denial.
Remember that liposuction for lipedema is for most carriers not in their fee schedule, most account representatives will hear “liposuction” and think cosmetic=denied and tune you out. Many will never have heard of lipedema. Make your case immediately and up-front why it should be paid in an organized manner (following the checklist).
Thanks and Good Luck
Jeffrey P. Restuccio, CPC, COC, MBA