Posts Tagged medically necessary
Breast reduction is misunderstood online. The operation is defined as the reduction and lifting of breasts. This is not the same as removing or reducing the size of breast implants in a woman’s breasts. That is called an implant exchange.
Implants are not usually involved especially when an insurance company is scheduled to pay for it with the possible exception of surgery to reconstruct a woman’s breasts after breast cancer surgery.
It is difficult enough to get most insurers to pay for “clear cut” medically-necessary plastic surgery. Breast reduction surgery is the reduction of naturally enlarged breasts and that is all.
Breast reduction used to be one of the more common insurance-covered procedures in my Orange County plastic surgery practice. With the economy as of late, insurers are not always so quick to approve them, but for the right patient they are still do-able.
Usually we see our patients for a consultation and then apply to their insurers for pre-approval if the cases seems reasonable by insurance company standards. We don’t make the rules on approval, but we do know the game. Appeals are not uncommon.
These days insurers are looking for a certain amount of breast gland to be removed in a certain sized woman in order to allow coverage. In addition they like to see documentation of things like bra strap furrows, the “dents” some larger breasted women get in their shoulders from breasts weighing against them over the day. Insurance pre-approval usually covers surgery for a 90 day period. The exact nature of that coverage varies by the plan.
Insurers don’t tend to like claims is which liposuction has been involved. This can trigger denials on cosmetic grounds at the time of billing. In cases of breast implants in larger breasts, we have staged the surgery to avoid insurance denial. That means taking the implants out in one operation and waiting several months to a year before re-operating for breast reduction. It might sound silly, but again we don’t make the insurer’s rules regarding payment.
John Di Saia MD
According to the most recent estimate from The Centers for Medicare and Medicaid Services (CMS), overall U.S. healthcare spending in 2009 was $2.5 trillion. CMS reports that $505 billion accounts for physician and clinical services. According to data from Medical Group Management Association (MGMA), physician compensation accounts for 37 percent of total collections, or $186 billion (7.5 percent of total U.S. healthcare spending).
Calculating the percentage using the most recent statistics on the number of practicing physicians in the U.S. from the American Medical Association and salary figures from MGMA, annual aggregate physician salaries total $216 billion, or 8.6 percent of total U.S. healthcare costs. The MGMA statistics were obtained from a 2010 report using 2009 data. Source: jacksonhealthcare.com/media-room/press-releases/md-salaries-as-percent-of-costs.aspx
People have a tendency to believe that doctors make bank in their health care. We are often targeted by those who believe that health care spending would be better if we took a pay cut. According to the national statistics however, physician payments amount to less than 8% of the pie. Relative to overhead, plastic surgeons who do medically necessary work (particularly emergencies) are routinely underpaid. That is a fact.
If it weren’t such a bleak picture in health care do you think that so many doctors not trained in residency as plastic surgeons would be performing cosmetic surgery? When you need a plastic surgeon in an emergency and one if not available, now you might know why.
John Di Saia MD
A blogger came by and left the following comment:
Our skin obsessed society is sick. Plastic surgeons only exasperate the problem. Isn’t the job of doctor to do things that are medically necessary or prudent? Is giving some stupid celebrity bimbo bigger knockers medically necessary? Are people insecure little children that are nothing more than shallow materialists ? I guess so.
Source: fakieollie.com/blog (Brian)
This is funny really as the poster clearly has very little idea of how the practice of plastic surgery works. Most medically-necessary plastic surgery is performed in my geographic region by doctors who do not have busy cosmetic practices. The reason is pretty simple: because your insurance company pays a plastic surgeon poorly for it. Although I am sure the poster feels quite righteous in making his point, medically-necessary plastic surgery alone cannot keep a practice solvent. Cosmetic surgery is necessary to pay the bills. Most of us eventually do mostly cosmetic surgery, because we figure we should be able to live reasonably well for the years we took in training to get here.
John Di Saia MD