The New You Plastic Surgery is proud to be the leading industry experts in insurance based plastic surgery. See below some common questions about health insurance policies and how your benefits may cover medically necessary plastic surgery procedures.
Like many Board Certified Plastic Surgeons, Dr. Nikfarjam is considered out-of-network. For patients that meet the criteria for medical necessity, our office can try to pre-authorize or bill to any plan that offers out-of-network benefits.
Please keep in mind- each insurance policy is unique in terms of medical necessity criteria, deductibles, co-insurance, and plan exclusions. Your case will be evaluated individually to best ensure accurate and complete information.
- What does “out- of- network” mean?
Many insurance policies allow for access to both in-network and out-of-network providers. The reimbursement structure and patient responsibility structure may differ between in and out of network providers. This information is easily attainable by looking at your plan benefit detail booklet, by calling the phone number on the back of your insurance card, or by speaking to a HR person who enrolled you in the plan.
If you have out-of-network benefits, you are entitled to use them!
Medicare and Medicaid plans do not offer out-of-network benefits. Most plans labeled EPO or HMO do not offer out-of-network benefits.
- Can I change my policy if I don’t have out-of-network benefits?
Your insurance policy should fit your/ your family’s lifestyle and budget. If you are seeking new coverage, you should speak to the person who enrolled you in the plan to find out if there are other plan options and when you may be eligible to switch policies.
- What is Pre-Authorization?
You may have heard the term “pre-authorization” or “prior authorization” as something that is required prior to scheduling a particular type of procedure. Some insurance carriers require this for certain imaging studies, specialty services, and even some prescriptions. They very often apply this requirement to surgical procedures. From the insurance company’s point of view, they want to ensure that a procedure or treatment is appropriate in a given situation and that a more conservative (cost-effective) option isn’t available.
For example: A patient is suffering from back pain and also has very large breasts. The patient should attempt to use conservative methods first (chiropractic care, Ibuprofen, specialty support bras) before resorting to a Breast Reduction surgery. Only after those methods have tried and failed, would a more aggressive (expensive) measure would be considered.
When policies require pre-authorization on a certain procedure code, it means that they will not pay for the service unless that pre-authorization has been obtained. This pre-authorization is not a formal guarantee of payment; it is one of many strong pieces of medical necessity evidence our team uses when we go to bill your claim after surgery.
- What if no pre-authorization is required?
Some insurance carriers will not require “pre- authorization.” If/when that is the case, our team will ask for a voluntary “pre-determination.” A pre-determination is similar to a pre-authorization in that our case is presented in front of a clinical reviewer at the insurance company who either agrees or disagrees with the reasoning we’ve established for the medical necessity of your procedure. Again, this is not a formal guarantee of payment but a strong piece of evidence to use when billing your claim.
In some rare cases, no pre-authorization will be required and the carrier WILL NOT consider a pre-determination. This puts both the patient and provider in a difficult position as neither party should want to enter into a situation that has no indication from the insurance carrier that they agree upon medical necessity and plan to pay.
In general, medical diagnoses and suggested treatments are not objective. This is especially true for plastic and reconstructive procedures. Those outside the field do not always share the same understanding of the conditions we treat and the improvements in lifestyle our procedures allow. Therefore, moving forward into a surgery with the burden to prove medical necessity after the fact can feel risky. These situations are handled individually by our office to present to you both best and worst case scenarios so you can make an informed decision, and be prepared financially.
- How long does it take to receive authorization/ approval?
Once your authorization is started, we typically have a final answer in 4-6 weeks. If any part of the initial request is denied, we will initiate the process of an appeal or a peer to peer review. If you receive a letter in the mail from your insurance carrier regarding a denial, no action is required on your part! Cases are often denied initially and then overturned. You can rest assured that Dr. Nikfarjam and our team will follow through every possible course of action in an effort to get coverage authorized for you. Hence, if your initial request is denied, it could take longer than six weeks to pursue the process of appeals and peer to peer reviews.
Once your insurance carrier has rendered a final decision, we will reach out to discuss the logistics of scheduling and pre-surgical testing requirements. Please be aware that your insurance carrier may offer only a specific window of time to have the procedure performed, as well as a specific facility.