After several months feedback has been to simplify, simply, and SIMPLIFY!<\/p>\n\n\n\n
I’ve updated the checklist (Aug 14, 2020). I now have a one-page concise version plus a longer, three-page version.<\/p>\n\n\n\n
The guidebook will be updated shortly in Aug 2020 and is now over 50 pages. While personally I think all the information is valuable and worth saving $15-$30K over self-pay, many have asked for a shortened version.<\/p>\n\n\n\n
If you follow the checklist meticulously you should be able to obtain reimbursement from about 85% of insurance carriers. There will always be those 15% that will work extra hard to deny you. If you experience pushback or your pre-auth or claim is denied then you will need to read the guidebook and work the appeal process. Below are a PDF version and an Excel version of the Checklist.<\/p>\n\n\n\n
The Tips document above includes additional tips based on some recent insurance submissions. If you have any suggestions for improvement or something that I missed please let me know. I am updating this document often. The data-sheet SS below is required information you will need for reimbursement. The earlier you get it the better.<\/p>\n\n\n\n
Here is the short version below of the CHECKLIST:<\/p>\n\n\n\n After several months feedback has been to simplify, simply, and SIMPLIFY! I’ve updated the checklist (Aug 14, 2020). I now have a one-page concise version plus a longer, three-page version. The guidebook will be updated shortly in Aug 2020 and is now over 50 pages. While personally I think all… Continue reading 1<\/td> LIPOSUCTION FOR LIPEDEMA REIMBURSEMENT: Determine with your managing Provider that all conservative measures have been exhausted and surgery is the next and only option. Asterisk * [right] means additional information is available.<\/td> <\/td><\/tr> 2<\/td> Make a decision for surgery (in the future). [Website: www.lipoforlipedemareimbursement.com]<\/td> <\/td><\/tr> 3<\/td> Review your insurance policy for coverage information.<\/td> *<\/td><\/tr> 4<\/td> Read your carrier manual for exclusions.<\/td> *<\/td><\/tr> 5<\/td> Check if there is a state or ins. Co. ombudsman or advocate. Medicare has one.<\/td> *<\/td><\/tr> 6<\/td> Should you pay for a reimbursement advocate? See question list.<\/td> *<\/td><\/tr> 7<\/td> Begin collecting Provider documentation 6 months or more in advance.<\/td> <\/td><\/tr> 8<\/td> Obtain doctor letters and documentation. See below<\/td> *<\/td><\/tr> 9<\/td> Find a qualified surgeon familiar with liposuction for lipedema.<\/td> *<\/td><\/tr> 10<\/td> Many liposuction for lipedema experts are not contracted with insurance companies.<\/td> <\/td><\/tr> 11<\/td> Many liposuction for lipedema experts are not not board-certified plastic surgeons.<\/td> <\/td><\/tr> 12<\/td> Most surgeons require payment up-front before pre-authorization and approval. Confirm.<\/td> <\/td><\/tr> 13<\/td> Most all approvals are case-by-case. Make your case the best.<\/td> <\/td><\/tr> 14<\/td> Is the surgeon in network or out? (Most likely not contracted and out of network).<\/td> *<\/td><\/tr> 15<\/td> Plan may recommend an in-network board-certified plastic surgeon with no lipedema experience.<\/td> <\/td><\/tr> 16<\/td> If your surgeon is out-of-network you may need to negotiate a Single Case Agreement (SCA).<\/td> *<\/td><\/tr> 17<\/td> Specifically request an “out-of-network” exception so they pay in-network fees.<\/td> *<\/td><\/tr> 18<\/td> There are no fee schedules for liposuction surgery (reimbursement can be any amount; case by case).<\/td> *<\/td><\/tr> 19<\/td> Establish number of treatments and that the ins. co. will reimburse.<\/td> <\/td><\/tr> 20<\/td> The more info you send with the pre-auth the better.<\/td> *<\/td><\/tr> 21<\/td> The patient can provide a cover letter introduction and summary. Be concise and to the point!<\/td> *<\/td><\/tr> 22<\/td> Send Photos with pre-auth info. Determine how best to deliver them.<\/td> <\/td><\/tr> 23<\/td> Expert Opinion Letters (EOL) need to support surgery as reconstructive and medically necessary.<\/td> *<\/td><\/tr> 24<\/td> Recommend doctors document stages.<\/td> *<\/td><\/tr> 25<\/td> Doctor must document progression and how liposuction will help.<\/td> <\/td><\/tr> 26<\/td> Send documentation notes of at least six months of conservative treatment.<\/td> <\/td><\/tr> 27<\/td> Provider letters should state that all conservative treatments have failed and the progression of the disease will worsen without surgical treatment.<\/td> <\/td><\/tr> 28<\/td> If overweight address obesity management explicitly.<\/td> <\/td><\/tr> 29<\/td> Include all relevant doctor progress notes and diagnostic tests.<\/td> <\/td><\/tr> 30<\/td> Doctor must document that the patient has been compliant with all treatment.<\/td> <\/td><\/tr> 31<\/td> Address comorbidities and any safety issues concerning treatment.<\/td> <\/td><\/tr> 32<\/td> The treating physician must submit a Certification\/Letter of Medical Necessity (LMN) form.<\/td> <\/td><\/tr> 33<\/td> Get EOL letters from ALL your specialists!<\/td> <\/td><\/tr> 34<\/td> Obtain Pre-Authorization. Need approval, amount, and number of sessions.<\/td> *<\/td><\/tr> 35<\/td> Get contact information from everyone you speak to! Ask for e-mails.<\/td> <\/td><\/tr> 36<\/td> Some ins. Co. will send your claim to an External Review Board. This may increase the approval time.<\/td> *<\/td><\/tr> 37<\/td> If clinic does not file the claim you will need to submit the insurance claim.<\/td> <\/td><\/tr> 38<\/td> If the ins. co. agrees to pay the clinic (per SCA), submit CMS-1500 form; patient pay is the CMS-1490 form.<\/td> *<\/td><\/tr> 39<\/td> Some ins. Co may approve in 3 weeks. Others may take months.<\/td> <\/td><\/tr> 40<\/td> Doctor confirmed. Send Compression stocking care doco.<\/td> <\/td><\/tr> 41<\/td> Doctor confirmed. Send Combined decongestive therapy (CDT) doco.<\/td> <\/td><\/tr> 42<\/td> Doctor confirmed. Send Manual Lymphatic Drainage (MLD) doco.<\/td> <\/td><\/tr> 43<\/td> Doctor confirmed. Send Lymphedema therapy doco.<\/td> <\/td><\/tr> 44<\/td> Doctor notes: include pain measurements.<\/td> <\/td><\/tr> 45<\/td> Doctor notes: surgery will improve functionality.<\/td> *<\/td><\/tr> 46<\/td> Doctor notes: surgery will improve mobility and gait.<\/td> *<\/td><\/tr> 47<\/td> Doctor notes: surgery will improve Quality of Life.<\/td> *<\/td><\/tr> 48<\/td> Doctor notes: “surgery will restore to a (more) normal appearance.”<\/td> *<\/td><\/tr> 49<\/td> Add to above: “of a malformed body part.”<\/td> *<\/td><\/tr> 50<\/td> Once all documentation is assembled, contact the ins. co. for pre-auth; expect 3-12 weeks. Case-by-case.<\/td> <\/td><\/tr> 51<\/td> Send the ins. co. all requested information (and whatever additional you have).<\/td> <\/td><\/tr> 52<\/td> If denied you can appeal multiple times and levels; Medicare has five official levels.<\/td> *<\/td><\/tr><\/tbody><\/table><\/figure>\n","protected":false},"excerpt":{"rendered":"