Blue Cross Breast Reduction Denial After Pre-approval

Healthcare insurance companies are and have for some time been on my short list for contempt.

They underpay, take forever to pay, deny after approval and rescind for fun. Why should I not pitch them the BS they deserve in return?

This post was originally written following my receipt of a particularly funny (and O-So-Typical) letter concerning a woman for whom I performed breast reduction a few weeks ago. The involved breast reduction case was the largest I had done at the time with over 4 pounds of breast tissue in the removed specimen. Following surgery her back pain was gone and she could stand up straight. And her husband looked like a worked-up fiancé (amongst the best compliments in my book).

Bottom Line: This case was medically-indicated and I did a great job. Sorry Blue Cross.

Nevertheless, Blue Cross via letter issued a denial/delay of payment after the surgery had been performed (and after their own pre-operative approval). They are trying to make payment the responsibility of the HMO arm of her insurance plan. I am not an HMO provider. They know it won’t work, but it will delay payment.

This is and was Health care Insurance Company B.S. Maneuver #1 from the “We’re Cornered But We Can Still Delay The Payment” chapter.

They know this abuse is amongst the reasons doctors drop insurers. I can certainly see why many of my friends have done so. I actively follow rates of payment and denials as I decide to whom surgery should be offered. This is simply common sense. Surgeon needs to make a living too folks.

Best Regards,

John Di Saia MD

Originally posted 2005-06-30 20:09:00.

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Mohs Surgery and Plastic Surgery – How Does This Work in Orange County?

Mohs surgery is surgery for the removal of skin cancer which is common in Orange County due to our “sun sitting tendencies.” It is mostly offered by dermatologists and is specifically designed to remove the cancer with a low recurrence rate. Derms generally perform it under straight local (numbing shots in the office) and it is quite profitable for them. In this case the procedure to make the hole (that is what Mohs does) pays much better than the surgery to repair that hole. Some Derms in Orange County try to use Moh’s for nearly everything as it is profitable. This is not always in the best interests of the patient.

At times a dermatologist will refer the patient to a plastic surgeon for the closure after the Mohs is complete. This can be upsetting to the patient because unless it is arranged ahead of time, the plastic surgeon may not be able to get the patient scheduled for a few days.

You may have seen people walking around with large bandages on their ears or noses. They may not have had accidents as you might have thought.

An alternative is to have the skin cancer surgery performed entirely by a plastic surgeon which can decrease the patient’s total expense and allow for anesthesia and completion of surgery in one day. The plastic surgeon may order a frozen preparation of the removed tissue in the operating room (called frozen section) and the results have a similar cure rate and often look a whole lot better. Many plastic surgeons will take cases like these as long as the cancer isn’t too small because we are paid less to remove the cancer with conventional surgery than the Derms get with Mohs.

Best Regards,

John Di Saia MD

Originally posted 2011-03-04 07:30:28.

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Weight Loss Tummy Tuck in 73 Year Old – Orange County, Ca

Weight loss tummy tuck surgery is tummy tuck surgery after significant weight loss. Here we have Before & After images of the oldest patient for whom I have ever performed abdominoplasty. She was 73 at the time of her tummy tuck, but a very healthy 73. She had of her own accord lost some 65 pounds and wanted her “fat apron” lifted from her tummy. After her internist cleared her for surgery, we went ahead.

weight loss tummy tuck

She recovered well and quickly after her surgery and was pleased with her outcome. This weight loss tummy tuck resulted in a loss of a few pounds. The patient had lost the majority of her weight beforehand. This is the way it usually works out. These operations are “cleanup” for the effects of large scale weight loss most often.

This woman does not look like a young woman after her surgery but looks much better than she did beforehand. That is the bottom line with cosmetic plastic surgery.

Best Regards,

John Di Saia MD

Related:

Dr D’s Website Tummy Tuck Section

Originally posted 2005-05-16 20:29:00.

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Good Plastic Surgery in the OC – Satisfying Facial Dog Bite Surgery

Orange County Dog Bite Plastic Surgery

I met “S” in the emergency department of an Orange County hospital I no longer serve. She had been bitten on the lip by a large dog and incurred a fairly nasty wound. The dog bite repair here wound was a careful cleaning, trimming and closure by yours truly in the emergency department under local anesthesia. Unlike the majority of emergency patients with poor insurance coverage, this woman paid her bill slowly over about a year in payments.

She had a very nice outcome. It is too bad I can’t afford to do more of these, but they pay poorly even when insured and most patients are not as honorable as this one was. Good plastic surgery is not always cosmetic although cosmetic surgery pays most of our bills.

Best Regards,

John Di Saia MD

Originally posted 2011-09-23 07:30:34.

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Safe Labiaplasty or Vaginoplasty – Possible?

Clients come to the office frequently anxious about considering surgery of their genitals. Many are understandably worried as the impressions online from those having elective genital surgery vary enormously. Some had had a great experience and others warn of the “dangers.” Not all surgery of the genitals is performed the same way and the results vary with the technique and experience. Then again you can’t expect all operations done “down there” to address the same issues.

As I have written here before, I limit the operations I do in the genitalia to labiaplasty, specifically modification of the outer structures. These are usually reductions. Some are designed to reduce the discomfort of patients with larger lips (usually the Labia minora) and others are for more cosmetic issues like “evenness.” Vaginoplasty refers to operations on the inside of the vagina. These are frequently designed to tighten things internally. Some labiaplasty patients report increased “tightness” after surgery, but this is not usually the case.

My personal opinion is that vaginoplasty operations are higher risk…risk to internal structures and often the nerves. Long standing pain after vaginoplasty is not as uncommon as it is in properly performed labiaplasty surgery. My patients tend to have a pretty good experience.

Be sure if you are to consider an operation of your genitalia, that you review the risk and benefit of your specific operation before you decide to proceed. Realize that not all operations “down there” are the same and each one comes with its own risk/benefit profile. What different surgeons call “Labiaplasty” and “Vaginoplasty” also varies between surgeons. You need to ask an adequate number of questions beforehand to figure if the operation a particular surgeon is offering you might be right for you.

Best Regards,

John Di Saia MD

Originally posted 2011-06-28 07:30:56.

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Dr D in a Prius Poll?

Initial Post 11/3/11 7:30 AM

Hello all,

I am thinking of changing my ride. The idea of driving a Prius appeals to me. I get to use less gas which makes me feel a bit better about not contributing so much to our pollution and gas industry problems. There are a few environmentalist quirks I picked up as a Berkeley undergrad. :) The nerd in me likes efficiency and with the miles I drive I might need to stop less frequently. Some of the docs around me have commented that they are not so sure my clients will take well to their plastic surgeon driving a more green machine however.

So you can vote on it:

<a href="http://www.sodahead.com/fun/should-a-plastic-surgeon-like-dr-d-drive-a-prius/question-2259327/" title="Should a Plastic Surgeon Like Dr D drive a Prius?">Should a Plastic Surgeon Like Dr D drive a Prius?</a>

Update 9/26/12 – I have had my Prius for nearly a year and really love it. It is not a really sexy ride but I have been over that for years. It has been reliable and not stopping for gasoline so much has been pretty cool. The AC could be a bit stronger, but otherwise I am happy.

Best Regards,

John Di Saia MD

Originally posted 2011-11-03 07:30:41.

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Reader Request: Pressure Ulcer Surgery

“My mother has been paralyzed for many years and needed many surgeries. She has had a problem after a recent pressure ulcer surgery. The wounds have opened. Can you help her out? Her recent pressure wounds had been there for over a year and weren’t healing.”

Occasionally this blog connects me with potential patients who live locally in Orange County. I rarely meet this kind of person via the blog however and am not always able to help patients after recent surgery by another surgeon. With pressure ulcer surgery on large open wounds there are periods of opportunity during which surgery has the best potential. Right after an operation complicated by wound disruption, the wounds are frequently fragile and need to heal for a while before surgery can be performed successfully.

Pressure ulcer surgery is difficult in that it requires a protracted period of care after the operation itself. Medicare restricts how long a patient can be kept in an acute care hospital, so I do these cases in a long term acute environment (LTAC.) I specifically do the cases in an LTAC that I frequent. Other surgeons deal with these cases differently. Not many plastic surgeons spend much time doing decubitus ulcer surgery. These cases take time and are not infrequently complicated even when everything is optimal.

Pressure ulcer surgery is also best accomplished with a motivated patient who is ready and able to restrict pressure to the newly operated wound. Patients who sit on their newly-operated wounds shortly after surgery have poor success rates.

Best Regards,

John Di Saia MD

Related Posts:

Pressure Wound Surgery in Orange County

Originally posted 2011-11-09 07:30:11.

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Reader Question: Did You Do Labiaplasty on Stacie Halas?

Stacie Halas is a science teacher in an Oxnard middle school who was put on administrative leave while her bosses looked into the allegations that she was moonlighting as a porn star.

The question was probably put to me in jest, but I couldn’t tell you if I had operated upon her without her permission anyway. Have you ever heard of HIPAA? Patients have their privacy on health care information whether they are accused on moonlighting in the adult industry or not. It is not like most labiaplasty patients volunteer much private information about themselves. Their operations are pretty private in the vast majority of cases anyway.

Another equally important point is that I haven’t seen a single image identifying Ms Halas, so I wouldn’t know if I had operated upon her or not.

Best Regards,

John Di Saia MD

Originally posted 2012-03-09 07:30:29.

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Health Insurance Company BS – Out Of Network Edition

After receiving a payment denial letter from an insurer for an operation I performed a few months ago, I figured it was time to share.

Health insurance companies play endless games with your local doctor in order to delay or avoid paying the bill.

Let’s talk by means of example:

Mr M is a 50 year old man who was admitted to a long term care hospital when I first saw him. He had a large wound on his hip that was big enough to allow both of your fists to fit inside. Wound care resulted in a clean, but very large hole. The doctors taking care of him requested the assistance of plastic surgery to shorten what would have been a 6-12 month expected healing time.

This patient has commercial medical insurance. I am the only plastic surgeon who works at this hospital. After seeing him and interfacing with his insurance company they agreed to the surgery. I even had to speak with some kind of insurance company medical director who requested that the patient be allowed to be discharged home prior to the operation, a skin graft.

Four months after the patient’s surgery and a successfully healed wound, his insurance company denied payment for the surgery due to the fact that I am not a provider for his insurance. This is BS.

As I am the only plastic surgeon who sees patients at this hospital, we will probably win on appeal, but the point is that it shouldn’t be a hat trick to get paid for work you have done months prior. This is amongst the reasons that many plastic surgeons do little if any “real medicine.”

Your health insurance company is not beyond this kind of BS either.

Best Regards,

John Di Saia MD

Originally posted 2010-08-12 07:30:10.

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Reader Question: Redo Tummy Tuck Pictures?

I am looking into a Redo Tummy Tuck here in the OC. Why do you not have redo Tummy Tuck images on your site?

Revision plastic surgery is an uncommon part of a practice’s cases (in the right practice of course,) but a more difficult part of plastic surgery. And tummy tuck surgery is one of the larger scale operations your plastic surgeon can perform.

Because of these issues the results in redo tummy tuck surgery will vary quite a bit. Most surgeons are a bit hesitant to place these kinds of results on their web sites for fear of scaring away the “first time” tummy tuck patients. Even a good revision case result image tends to pale in comparison to an average first time operation in which a complication did not develop.

Suffice it to say that a good deal in the land of plastic surgery relates to impressions.

Best Regards,

John Di Saia MD

Originally posted 2011-06-22 07:30:21.

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