Frequently Asked Insurance Questions

As a breast reconstruction patient you are about to encounter numerous doctor, hospital, pathology and anesthesia bills. Remember, breast reconstruction is a long and staged process. One of the most common questions among breast cancer patients is "Will my insurance cover this?" In most cases the answer is yes. While insurance coverage varies on a patient by patient basis there are some things about insurances that do not change. Click here to view breast reconstruction state laws for each of the US states.

• What is a Deductible?
• What is a Copay?
• What is Co-Insurance?
• What is an Out-of-Pocket Maximum? And, how do I reach that?
• What is an Allowable?
• What is Balance Billing?
• What is a Global Period?
• What is an In-Network or Out-of-Network Provider?

What is a Deductible?
A deductible is the amount you (the patient) must pay for medical expenses prior to your insurance carrier paying benefits. Deductibles generally run on a calendar or fiscal year and are generally due annually.

What is a Co-Pay?
A co-pay is a fixed dollar amount that is to be paid by the patient each time the patient is seen for medical services. Co-pays do not apply towards a patient's deductible.

What is Co-Insurance?
Co-insurance is the amount shared by you and your insurance carrier for medical expenses. For example, in an 80% / 20% co-insurance plan, the insurance carrier pays 80% of the allowed charges and the patient pays 20% of the allowed charges. Please remember that your insurance company will not begin paying for medical expenses until your deductible has been met.

What is an Out-of-Pocket Maximum? And, how do I reach that?
An out of pocket maximum is a specific dollar amount that a patient is to pay per calendar year. Patients reach their out-of-pocket maximum through their co-insurance payments. For example, if you have a $1,000 out-of-pocket maximum and an 80%/20% insurance plan you will pay 20% of all allowed charges until you have paid $1,000. Once you reach your out-of-pocket maximum your insurance carrier will begin covering all services at 100%. Remember, co-pays are not included in out-of-pockets.

What is an Allowable?
An allowable is an agreed or contracted rate between your insurance carrier and provider for a specific service. This is what the insurance company pays the doctor.

What is Balance Billing?
Due to shrinking insurance reimbursements to physicians some DIEP surgeons set their fee and ask the patient to pay the remaining amount that the insurance company will not cover (ie the difference between the doctor's fee and the Allowable). This is known as "balance billing". This can add 10's of thousands of dollars to the patient's final bill and is in addition to the out-of-pocket expenses described above. PRMA does NOT balance bill.

What is a Global Period?
A global period is a specific period of time (generally 90 days after a surgery) that the patient receives follow-up care and post-operative visits without billing the insurance company. Patients must wait until their global period is complete prior to proceeding with the next stage of their breast reconstruction. Global periods are federally mandated and cannot be changed.

What is an In-Network or Out-of-Network Provider?
An In-Network provider is a physician or practice who has signed an agreement with your insurance carrier to accept a specific fee for services provided.
An Out-of-Network provider is a physician or practice who does NOT have a signed agreement with your insurance carrier. Out-of-Network providers are not required to "write-off" any monies for services rendered, and  you may be responsible for any dollar amount not paid by your insurance carrier.
**It is important to know whether your physician is considered In-Network or Out-of-Network for your insurance. Please be sure to ask our office staff. All our physicians are In-Network for all major US insurance carriers.