After accumulating hundreds of pages of information on how to be reimbursed for liposuction for lipedema, we now has the issue of “how insurance-friendly” is your chosen surgeon.”
There is additional information on all of the specific terms in this article on this website.
If you download the one-page checklist you will notice that getting reimbursed starts six-months before the surgery and all of your Providers and the surgeon need to cooperate with providing the necessary documentation—and the verbiage necessary to demonstrate the surgery is reconstructive, medically necessary and not cosmetic.
If reimbursement is important to you, then you need to identify “insurance-friendly” versus “insurance-uncooperative” surgeons. You will find that some very good liposuction for lipedema surgeons are insurance hostile–they won’t even help you file the claim yourself and be self-paid and do everything to dissuade you and even sabotage your efforts for reimbursement.
Here is how to identify your surgeon. And, of course, you can contact me when evaluating surgeons in regard to reimbursement. This has nothing to do with the surgeon’s qualifications; the issue is that some of the best liposuction for lipedema surgeons are primarily cosmetic and are not contracted with any insurance companies, have no ability to file claims and their staff has no experience with filing claims. But given those limitations they may still be very cooperative in helping the patient file their own claim; and some won’t be cooperative at all.
It would be sad that the qualified surgeon you’ve selected, whom you like, refuses to cooperate with medical insurance reimbursement—and then discover that another patient was able to get both an Out-of-Network Exception and the entire bill paid for multiple procedures from a different surgeon. That happens.
Top of the list of insurance-friendly would be a surgeon who is part of a University or plastic surgery group that performs a lot of reconstructive, insurance-paid procedures. And they are in-network with most carriers. They will have experienced reimbursement specialists on staff and should be able to provide everything you need and may submit the pre-authorization and file the claim for you. To determine if you surgeon is “insurance-friendly” look for the following:
- Surgeon is willing to provide an Expert Opinion Letter that includes the four components that qualify the procedure as reconstructive. Some may want to write one that is clinically accurate, but my template helps them to think like an insurance company. Some are just fine with it and others will resist (don’t tell me how to document my notes!).
- Including the four components that qualify as reconstructive does not in any way impact their clinical discussion of the condition and its progression. My notes have been reviewed by some of the leading experts in lipedema. I am an experienced medical coder, trainer, and auditor and I’ve personally reviewed over 10,000 medical records in my career. That is a lot of documentation. Words matter, and every bit of accurate documentation increases the probability that you will be reimbursed.
- Surgeon is willing to accept a Single Case Agreement (ask). Be clear that if there is a Balanced-Billing clause that it will mean that they must accept the reimbursement as Payment-In-Full. Many do not want to accept this. You may need to submit the price of the procedures and the number of procedures as part of the SCA. With an SCA the surgeon is paid; without one you can be paid directly.
- Surgeon is willing to send documentation to the insurance company with photographs.
- Surgeon and staff understand the difference between a cosmetic procedure and a reconstructive one. This is usually reflected on their website.
- I have some surgeons on speed-dial; others, who purport to file insurance, have never returned a phone call or e-mail.
- If the clinic appears to be insurance-friendly then it’s a good practice to give them a small task and see if they follow through. Or you could ask a few questions and compare their answers to my instructions. One is simply ask the surgeon how he/she determines if the procedure is reconstructive or cosmetic. Frankly, few will get this correct as their medical school definition is not the same as a reimbursement, insurance carrier definition. Their openness to learning how to meet the insurance carrier requirements will help you assess how helpful they will be.
Insurance-Neutral
A clinic is neutral if they, with a little prodding, provide you with enough information to file your own claim for self-reimbursement. They may submit the pre-authorization or require you to do it—the process can be very time-consuming. Sometimes the insurance company will only talk to the clinic so you need to discuss that possibility. You also need to discuss the issue of the SCA and the clinic needs to be willing to at least entertain accepting it. That’s important. If they indicate that they won’t accept any SCA under any circumstances that is not a deal breaker as you could still file for the insurance company to pay you as the patient directly.
Insurance Uncooperative / Hostile
Here is how you identify a surgeon or clinic that won’t help with insurance reimbursement in any way. They may actually interfere with your efforts to be self-paid.
- They categorically state that the surgery is cosmetic.
- They categorically state that no insurance company reimburses for the procedure.
- They won’t provide you with either a CPT procedural code or ICD-10-CM diagnosis codes.
- They won’t provide an Expert Opinion Letter so you can file your own claim.
- They won’t provide documentation or photographs for your insurance claim.
- The surgeon and staff do not understand that liposuction for lipedema, is, by definition a reconstructive and medically necessary procedure and the surgeon does not determine that. Some cases may be deemed not severe enough or the patient is too sick for the procedure, but you should determine if you meet the reconstructive criteria before you meet with any surgeon.
- The surgeon could sabotage your efforts by including terms like “improve appearance,” “aesthetic” or “contouring” in the documentation.
- They won’t discuss an SCA.
- Their website only refers to liposuction as a “cosmetic” procedure.
- They don’t use terms like tumescent liposuction, lymph-sparing liposuction, or water-assisted liposuction. All are common in reference to the more-complicated liposuction for lipedema procedure.
- They complain that the amount of insurance reimbursement is too low or they cannot be bothered with any of the paperwork necessary for reimbursement.
- The surgeon should still have a Clearance for Surgery letter, which could be separate from one outlining your lipedema, its progression, how conservative measures have failed, and how the surgery meets the four reconstructive requirements. You would need to request this to send to the insurance carrier. While some combine the two, one simply states that the patient is well enough for the surgery; the other makes the case that it is reconstructive.
Could you file a claim for self-payment anyway? Technically if you had your photographs and at least two Expert Opinion Letters you could. But the deck is heavily stacked against you. With an “insurance-friendly” surgeon and impeccable documentation and a strong case, over 50% of claims should be paid. My guess is that number could be even higher. Remember that most insurance companies reimburse on a case-by-case basis. Therefore the strongest cases, the best preparation, and the best documentation wins.
If you are interviewing liposuction for lipedema surgeons, please use the information above to determine if you surgeon is “insurance friendly.”
Please download additional information from my website or the Reimbursement Guidebook (now over 74 pages). You can use the Search feature to find specific terms. Contact me if you have additional questions.