The most recent Excel version of the checklist is above.
1 Liposuction for Lipedema Reimbursement CHECKLIST. Asterisk * [right] means additional information is available on www.lipoforlipedemareimbursement.com [December 2, 2020] Check website for updates.
2 Make a decision for surgery (in the future). [Website www.lipoforlipedemareimbursement.com]
3 Review your insurance policy for coverage information. *
4 Read your carrier manual for exclusions, E/I/U, reconstructive versus cosmetic policy, and appeals. *
5 Check if there is a state or ins. co. ombudsman or advocate. Some carriers will have one. *
6 Should you pay for a reimbursement advocate? See the advocate question list on website. *
7 Find a qualified surgeon familiar with liposuction for lipedema. *
8 Many liposuction for lipedema experts are not contracted with insurance companies.
9 Many of the best liposuction for lipedema experts are not board-certified plastic surgeons.
10 Plan may recommend an in-network board-certified plastic surgeon with no lipedema experience.
11 Is the surgeon in-network or out? (Most likely not contracted and out-of-network). *
12 Most surgeons require payment up-front before pre-authorization and approval. Confirm.
13 If your surgeon is out-of-network you may need to negotiate a Single-Case Agreement (SCA) [See GB]. *
14 Specifically request an “out-of-network” exception so they pay in-network fees. *
15 Most all approvals are case-by-case. Make your case the best.
16 Collect Provider documentation 3-6 months in advance. See patient Data Sheet on website.
17 Collect CPT, ICD-10-CM codes, Provider NPI (National Provider Identifier) and tax ID numbers.
18 Recommend doctors document stages. Note that there is no ICD-10-CM code specifically for lipedema. *
19 There are no fee schedules for liposuction surgery (reimbursement can be any amount; case by case). *
20 Establish number of treatments and that the ins. co. will reimburse.
21 Expert Opinion Letters (EOL) need to support surgery as reconstructive and medically necessary. *
22 Get EOL letters from ALL your specialists! The more the better. *
23 The more info you send with the pre-auth the better. *
24 Reimbursement is contingent on disease progression as worsening and how liposuction will help.
25 Provider letters stating that conservative treatments have failed and the progression of the disease will worsen without surgical treatment support your reimbursement claim; no status or improvement hurts.
26 If overweight address obesity management explicitly. If normal weight address pain and functionality.
27 Include all relevant doctor progress notes and diagnostic tests.
28 Doctor must document that the patient has been compliant with all treatments.
29 Address comorbidities and any safety issues concerning treatment. This is a Clearance for Surgery.
30 The treating physician must submit a Letter of Medical Necessity (LMN) form. *
32 Send photos with pre-auth info. Determine how best to deliver them.
33 Send documentation notes of at least three months of conservative treatment. Include status of lipedema.
34 Doctor confirmed. Send Compression stocking care documentation.
35 Doctor confirmed. Send Combined decongestive therapy (CDT) documentation.
36 Doctor confirmed. Send Manual Lymphatic Drainage (MLD) documentation.
37 Doctor confirmed. Send Lymphedema therapy documentation.
38 ONLY document what is clinically accurate. If conservative measures are successful that must be documented. *
39 Doctor notes include pain measurements. Surgery will reduce pain.
40 Doctor notes surgery will improve functionality, mobility and gait. *
41 Doctor notes surgery will improve Quality of Life. Explain. *
42 Doctor notes “surgery will restore to a (more) normal appearance.” Add “of a malformed body part.” *
43 The patient can provide a cover letter introduction and summary. Be concise and to the point! *
44 If clinic does not file the claim you will need to submit the insurance claim.
45 If the ins. co. agrees to pay the clinic (per SCA), submit CMS-1500 form; patient pay is the CMS-1490 form. *
46 Get contact information from everyone you speak to! Ask for e-mails.
47 Some ins. co. allow filing a claim online. The ins. co may approve in 3 weeks. Others may take months.
48 Once all documentation is assembled, contact the ins. co. for pre-auth; expect 3-12 weeks. Case-by-case.
49 Obtain Pre-Authorization. You will need the charged amount and number of sessions. *
50 Send the ins. co. all the information that will support your case. Expect EOB within 14 days. Confirm.
51 Some ins. co. will send your claim to an External Review Board. This may increase the approval time. *
52 If denied you can appeal multiple times and levels; Medicare has five official levels. *
53 Persistence and attention to details is key. Follow this checklist carefully. You can win this! Jeff Restuccio