Health Insurance, Predetermination, and Plastic Surgery

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Health Insurance, Predetermination, and Plastic Surgery
November 19, 2008
Dr. Barry Eppley
Explore Plastic Surgery

Patients frequently consult plastic surgeons for procedures and medical conditions that they may feel is or should be covered by their health insurance. Sometimes this is true, other times it is not. Procedures such as breast reduction (female and male), abdominal panniculectomy after weight loss, and rhinoplasty (nose surgery) are common health insurance requests by patients. These are also plastic surgery procedures that are heavily scrutinized by medical insurances and a very specific list of eligibility criteria exist by which they may be deemed medically necessary or of a cosmetic nature. It is not up to the plastic surgeon or the patient to determine if such procedures are covered. That is determined by your health insurance through a process known as pre-determination. This must be done prior to the procedure being performed or it will be automatically rejected even if it otherwise may have been eligible for coverage.

Predetermination by health insurance companies is necessary for selected inpatient and outpatient medical services (including surgeries, major diagnostic procedures and referrals) to determine if they are medically necessary. It is fair to say that all plastic surgery procedures must be predetermined. Health insurances generally assume that if a plastic surgeon is doing the procedure it must be ‘cosmetic’ in nature. This is a process where your plastic surgeon writes a letter to your health insurance company providing them with a diagnosis, any supporting information that proves the problem is causing medical symptoms, and the operations that are needed to fix the medical problem. The key here is that there must exist medical symptoms such as pain, a recurring skin problem, or difficulty with breathing for example. Just because it looks bad or was caused by an accident or birth defect is not enough. (I don’t make the rules, I just have to live by them) Awaiting a response from this letter from your insurance company will take at least 30 days after it has been submitted. It is not a fast process so plan accordingly. Showing up in your plastic surgeon’s office on December 10th for an insurance procedure that you want to do before the end of the year will not work. There simply is not enough time to get it predetermined.

For the member to receive benefits for a plastic surgery procedure, it must be authorized or “precertifed” prior to being rendered. Precertification, often used interchangeably with predetermination, is part two of the process. Precertification can help avoid unnecessary charges or penalties by ensuring that your plastic surgery care is done at an appropriate network facility and by a network provider. Predetermination and Precertication work hand in hand. Precertification is a much more rapid process that can be determined over the phone or by fax between the plastic surgeon’s office and the health insurance company.

Therefore, precertification includes a review of both the service and the setting. Medical care is covered according to the plan’s benefits…not what you think should be covered or how you feel it should be done. Health insurance is basically a business contract not an ethical or moral set of guidelines. Many services will require you to use a provider designated by the health insurance’s list of providers. For benefits to be paid, you must not only be eligible for benefits but the service must be a covered benefit under the contract at the time the surgery is performed.