Insurance Coverage - Frequently Asked Questions
One of the most common questions among breast cancer patients is, Will my health insurance cover breast reconstruction? In the vast majority of cases the answer is YES.
While insurance coverage varies on a patient by patient basis, there are some things that are pretty standard. The Women's Health and Cancer Rights Act (WHCRA) mandates insurance to cover breast reconstruction surgery if you have had a mastectomy. Breast reconstruction after prophylactic (preventive) mastectomy is also usually covered as long as the patient is deemed high risk for breast cancer (significant family history or BRCA gene positive).
Let Us Take Care Of Everything
Though knowing your breast reconstruction is covered is reassuring, it does not take away the added stress of trying to keep up with deductibles, co-insurance rates, and out of pocket maximums. After numerous office visits, various procedures, and reconstructive surgery, it can be difficult to keep all your bills organized.
The PRMA billing department is staffed with insurance and billing specialists to help ease this process. We have worked successfully for more than 20 years with numerous insurance providers to ensure proper coverage for our patients. We will submit your claims and follow up as necessary--keeping you fully informed along the way--until your claims have been paid. We always provide you with a cost estimate before surgery so you will know your financial responsibility up front. Below you will find answers to some of our most frequently asked insurance questions. For more information or if you have further questions, please give our billing department a call at 210-447-7829.
Financial assistance is available by other entities or third parties in some cases for those in need. Your local American Cancer Society is a great resource for information on organizations in your area that may be able to help. For patients in need living in San Antonio, Thrivewell Cancer Foundation may be an option to help offset some financial responsibilities. For more information visit http://thrivewell.org/patient-assistance/. You can find information on travel and accommodation assistance HERE.
For more information on your state breast reconstruction laws CLICK HERE.
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 year and are generally due annually.
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-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.
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% plan you will pay 20% of all allowed charges until you have paid $1,000. Once you reach your out-of-pocket maximum, your carrier will begin covering all services at 100%. Remember, co-pays are not included in out-of-pockets.
An allowable is an agreed or contracted rate between your carrier and provider for a specific service. This is what the insurance company (carrier) pays the doctor.
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.
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.
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 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 carrier. **It is important to know whether your physician is considered In-Network or Out-of-Network for your insurance plan. Please be sure to ask our office staff. All our physicians are In-Network for MOST major US carriers.
Typically the breast reconstruction process involves more than one surgery, including one "revision surgery" (performed as the second surgery). Most insurance plans cover all reconstructive stages. However, more than one revision surgery will likely not be covered by your insurance company, or deemed "medically necessary". Requests for surgery may be denied if the proposed procedure offers only a minimal improvement in the appearance of the enrollee, in accordance with the standard of care as practiced by physicians specializing in reconstructive surgery. Furthermore, secondary revisions will be considered cosmetic and cosmetic fee quotes will be provided.