Patient Resources

Insurance Coverage for Natural Tissue Breast Reconstruction

Welcome to our guide on breast reconstruction insurance coverage, where we help you understand your policy, patient rights, find active insurers, and explore coverage options.

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Introduction

Our Comprehensive Guide and Services as your Insurance Liaison

Whether you’re exploring your options or seeking clarity on existing coverage, this guide is your go-to resource for understanding and maximizing your insurance benefits for breast reconstruction.

Part 1:
Summary Plan Description

This document outlines what’s covered, any limitations, and what you’re responsible for. It’s the key to understanding what parts of natural tissue breast reconstruction might be covered under your plan.

Part 2:
Going Out-of-Network

Choosing out-of-network providers for natural breast reconstruction means seeking specialized care not covered by your insurance network, potentially resulting in higher out-of-pocket costs but allowing access to specific expertise or techniques not available in-network.

Part 3:
Understanding Fee-Schedules

Navigating fee schedules for natural breast reconstruction involves understanding the predetermined costs set by your insurer, impacting your out-of-pocket expenses and potential reimbursement rates for medical services.

Part 4:
Mapping Insurance Coverage

Explore our interactive insurance map, pinpointing regions dominated by specific insurance companies.

Our First Class Patient Care

Serving as Your Insurance Liaison

We understand that dealing with insurance processes can be overwhelming. That’s why we serve as your dedicated insurance liaison, taking the stress out of navigating the claims process.

> We investigate your benefits, provide personal case management and manage all of your insurance carriers requirements for pre-certifications or pre-determinations.

> Where applicable, we submit all of the billing on your behalf, and work directly with your insurance carrier on any appeals to ensure that you receive the full benefits to which you are entitled.

> We have worked successfully for more than 10 years with numerous insurance companies and plans including commercial, self-funded, union, and international as an out-of-network provider.

Summary Plan Description (SPD)

definition & details

The SPD is a detailed guide to the benefits your insurance program provides and how the plan works.

What’s Covered:
Identify sections specifying coverage for medical procedures, including natural tissue breast reconstruction.

Examples:

  • Surgical procedures related to mastectomy.
  • Hospital stays and associated costs.
  • Anesthesia and operating room charges.
  • Post-operative care, including follow-up visits.
  • Costs associated with natural tissue breast reconstruction.
  • Necessary medical tests and imaging related to the reconstruction process.
  • Rehabilitation services if deemed medically necessary.
  • Prosthesis or breast implants as part of the reconstruction.

Limitations:
Look for any restrictions or limitations related to the reconstruction process.

Examples:

  • Pre-authorization requirements.
  • Caps on expenses or maximum coverage limits.
  • Exclusions for certain types of procedures or treatments.
  • Specific criteria or conditions for coverage eligibility.
  • Time limitations for initiating the reconstruction process after mastectomy.

Section Navigation:
Familiarize yourself with the table of contents to efficiently locate relevant sections related to coverage.

Contact Information:
Find contact details for your insurance provider to seek clarification on any ambiguities in the document.

Your Role:
Understand your responsibilities outlined in the SPD, such as copayments, deductibles, or other out-of-pocket costs.

  • Paying copayments: Fixed amounts due at each healthcare visit.
  • Meeting deductibles: Initial amount you pay before insurance kicks in.
  • Covering out-of-pocket costs: Additional expenses beyond what insurance covers.

Financial Implications:
Gain clarity on how much you might be responsible for during the reconstruction journey.

  • Estimating costs: Understanding potential expenses for procedures and services.
  • Budgeting for copayments: Planning for regular, predictable healthcare expenses.
  • Accounting for deductibles: Being aware of upfront costs before comprehensive coverage begins.
  • Preparing for unforeseen costs: Anticipating unexpected out-of-pocket expenses during the reconstruction journey.
“Reconstructive Procedures”:
Check if the SPD explicitly mentions coverage for reconstructive procedures, including natural tissue breast reconstruction.

“In-Network vs. Out-of-Network”:
Understand the distinctions between in-network and out-of-network coverage.

  • In-Network:
    • Definition: Healthcare providers and facilities contracted with your insurance company.
    • Implications: Typically, lower out-of-pocket costs as the insurance plan has negotiated rates with these providers.
  • Out-of-Network:
    • Definition: Healthcare providers and facilities not contracted with your insurance company.
    • Implications: Higher out-of-pocket costs, as coverage may be limited, and negotiated rates may not apply.

Specifics:
Ensure the SPD provides specific information related to breast reconstruction, addressing questions about the procedures covered and any prerequisites.

  • Specifics:
    • Look for a clear statement on coverage for breast reconstruction procedures, including natural tissue reconstruction.
    • Check if the document outlines the specific surgical procedures covered in the reconstruction process.
    • Verify if there are any prerequisites or conditions that must be met for coverage eligibility.
    • Ensure the SPD provides detailed information on any associated costs, such as copayments or deductibles, related to breast reconstruction.
    • If there are exclusions or limitations, they should be explicitly mentioned in this section.
    • Seek clarity on the documentation or information required for pre-authorization, if applicable.

By examining these specifics in the SPD, you can gain a comprehensive understanding of how your insurance plan addresses breast reconstruction, allowing you to make informed decisions about your healthcare journey.

Reach Out:
If the SPD is unclear, do not hesitate to contact your insurance provider for clarification.

  • Contact Information:
    • Look for a customer service phone number provided by your insurance company.
    • Check if there’s an email address or online contact form for inquiries.
    • Examine the SPD for a dedicated section on how to get in touch with the insurance provider.
  • Questions to Ask:
    • Seek clarification on any ambiguous language or terms within the SPD.
    • Inquire about specific coverage details for natural tissue breast reconstruction.
    • Confirm any uncertainties regarding participant responsibilities and financial obligations.
    • Ask about the procedures for obtaining pre-authorization if needed.
    • Request information on how to appeal or dispute coverage decisions if necessary.
  • Documentation:
    • Keep a record of your communication, including the date, time, and the name of the representative you spoke with.
    • If discussing coverage details, request written confirmation or documentation for future reference.

In-Network vs. Out-of-Network

definition & details

In-network insurance refers to coverage provided by healthcare providers within a specific network, while out-of-network insurance covers services from providers outside that network.

Women’s Health and Cancer Rights Act:
Your Freedom to Choose Surgeons, In-Network or Out-of-Network:

It’s important for women to be aware of these federal rights and advocate for their choices in breast reconstruction.

The Women’s Health and Cancer Rights Act (WHCRA) ensures insurance coverage for breast reconstruction surgery, including procedures to achieve symmetry between the reconstructed breast and the unaffected breast, as well as coverage for prostheses and treatment of physical complications related to the mastectomy.

The WHCRA ensures that coverage extends to both in-network and out-of-network surgeons, allowing individuals to make decisions based on their preferences and medical needs. Key provisions include:

The Right to Choose Your Surgeon

WHCRA provides the right for women to choose their own surgeon, even if the surgeon is out-of-network.

This means that insurance plans must cover the costs associated with the selected surgeon, ensuring that women have access to the expertise and care they desire.

The Right to Access to Reconstruction Coverage

Insurance plans are required to cover all stages of breast reconstruction, including surgery and any necessary procedures on the opposite breast to achieve a symmetrical appearance.

This coverage is applicable whether the chosen surgeon is in-network or out-of-network.

Breast Reconstruction Without Bias or Discrimination

WHCRA prohibits insurance plans from discriminating against individuals based on their decision to undergo breast reconstruction or their choice of surgeon.

Women have the right to receive coverage without facing undue limitations or financial burdens.

Compliance Guidelines for the No Surprises Act: Ensuring Transparency and Protection in Healthcare Billing

The No Surprises Act mandates that individuals in health plans can waive balance billing protections under specific conditions outlined in the Public Health Service Act, provided they receive proper notice and consent documents.

Healthcare providers must offer clear information about balance billing restrictions and state law protections, while group health plans and insurance issuers are required to disclose these details and provide contact information for relevant agencies.

Frequently Asked Questions about Out-of-Network Coverage:

Going out-of-network can significantly impact coverage for natural tissue breast reconstruction.

Insurance plans typically have different rules and reimbursement rates for out-of-network services.

This means that while some costs may still be covered, the coverage percentage might be lower, resulting in higher out-of-pocket expenses for the individual.

Additionally, some insurance plans may require pre-authorization for out-of-network services, adding an extra layer of complexity.

It’s crucial to carefully review your plan documents to understand the specific terms and conditions related to out-of-network coverage for breast reconstruction procedures.

Our Practice Support: We serve as your dedicated insurance liaison, guiding you through the intricacies of out-of-network coverage. Our team ensures clarity on your insurance terms, assists in obtaining necessary pre-authorizations, and advocates for your comprehensive coverage throughout the breast reconstruction process.

The potential cost differences between in-network and out-of-network services can be substantial.

In-network providers have negotiated rates with the insurance company, leading to lower out-of-pocket expenses for policyholders.

 

On the other hand, out-of-network providers may charge their usual fees, which can be higher than the negotiated rates.

This results in individuals facing increased deductibles, higher copayments, and a larger share of coinsurance when opting for out-of-network services.

It’s essential to carefully consider these potential cost differences when deciding on the choice of healthcare providers for breast reconstruction.

While there might be out-of-network providers who specialize in breast reconstruction, finding them requires thorough research.

Individuals should consult their insurance provider for a list of out-of-network specialists and verify their expertise in breast reconstruction.

It’s important to consider factors such as the provider’s experience, credentials, and patient reviews to ensure that they meet the necessary standards for the procedure.

Additionally, reaching out to support groups, medical associations, or seeking recommendations from healthcare professionals can provide valuable insights into identifying reputable out-of-network providers specializing in breast reconstruction.

 

Navigating Options: We understand the importance of finding the right provider for your breast reconstruction. As your advocate, we assist in identifying reputable out-of-network specialists with expertise in breast reconstruction, ensuring you have access to the best possible care.

Minimizing out-of-network costs for your reconstruction journey involves proactive steps.

Firstly, check with your insurance provider to obtain a list of preferred in-network providers for breast reconstruction. Researching and choosing healthcare professionals within this network can significantly reduce out-of-pocket expenses.

Additionally, understanding the criteria for pre-authorization, obtaining necessary referrals, and confirming coverage details in advance can help prevent unexpected costs.

Regular communication with the insurance company, clarifying any uncertainties, and maintaining thorough documentation of interactions can ensure a smoother process and minimize out-of-network financial burdens during your reconstruction journey.

Practice Support System: Our practice acts as a support system, actively working to minimize your out-of-network costs. We assist in coordinating with your insurance provider, obtaining pre-authorizations, and providing transparent communication to keep you informed and empowered throughout your reconstruction journey.

Fee Schedules

definition & details

Fee schedules for natural tissue breast reconstruction outline predetermined charges set by insurance providers, detailing the costs for medical services and procedures related to the reconstruction process. These schedules affect patients’ out-of-pocket expenses and reimbursement rates, impacting their financial planning and decision-making during their reconstruction journey.

Key Aspects of Fee Schedules:

  • Maximum Charges:
    Fee schedules outline the maximum amount that healthcare providers are allowed to charge for specific medical services related to natural tissue breast reconstruction. Patients should carefully review these maximum charges to gain insight into potential costs associated with different aspects of the procedure.

  • Cost Transparency:
    Fee schedules provide transparency in understanding the costs associated with each stage of natural tissue breast reconstruction. Patients should look for detailed breakdowns in the fee schedules, including surgical procedures, hospital stays, anesthesia, and any other related services. This transparency enables patients to make informed financial decisions.

  • Network:
    Different fee schedules may apply depending on whether the healthcare provider is in-network or out-of-network. Patients should be aware of these distinctions and choose healthcare providers who align with their insurance network to optimize coverage and minimize out-of-pocket costs.

  • Negotiation Advocacy:
    Understanding fee schedules empowers patients to negotiate with healthcare providers. Patients may discuss fees, explore potential discounts, or inquire about payment plans. Advocating for transparent communication on fees ensures that patients can plan for the financial aspects of natural tissue breast reconstruction effectively.

  • Fee Limits:
    Fee schedules should align with the coverage offered by the patient’s insurance plan. Patients should check whether the fees charged by healthcare providers fall within the allowable limits set by their insurance company. This alignment is crucial for avoiding unexpected financial burdens.

Mapping Insurance Coverage

know your options

Explore our interactive insurance map, pinpointing regions dominated by specific insurance companies.

7060300 WY VT NM MS IA SD CO Massachusettes Hawaii GA WA ID OR OH AL AK AZ AR CA Connecticut Delaware IL IN KS LA ME MI Maryland KY MO FL MT NE NV New Hampshire New Jersey Rhode Island NY NC ND OK TX PA WI MN WV VA UT TN SC

Dr. Joshua L. Levine, MD, FACS

Advanced Microsurgeon in Natural Tissue Breast Reconstruction

“During my initial consultation, Dr. Levine made me feel at ease and safe; I immediately sensed his kindness, his empathy, his calm demeanor. I felt confident that I was in the best possible hands; his credentials and extensive experience speak for themselves but he also had a longstanding relationship with my breast surgeon who I trusted implicitly, and he came highly recommended.” – Patient Testimonial

Dr. Joshua Levine Breast Reconstruction Surgeon Welcome Text

Dr. Joshua L. Levine, MD, FACS
World Leading Authority in Perforator Flap Breast Reconstruction
Based in New York, New Jersey, and Connecticut

Dr. Joshua L. Levine is a world-renowned microsurgeon in natural tissue perforator flap breast reconstruction. He has been pioneering advancements in the field of perforator flap breast reconstruction since the beginning of his career in 2004, and has completed over 1,700 successful reconstruction procedures.

With his advanced techniques in autologous flap breast reconstruction, such as stacked combination flaps, or utilizing the delay phenomenon in staged-immediate reconstruction, all women, no matter how thin and no matter what body type, are candidates for natural tissue, muscle-sparing, implant-free breast reconstruction.

Dr. Levine has developed dedicated natural tissue breast reconstruction centers throughout New York, New Jersey and Connecticut. He works with expert breast surgeons and has personally directed the advanced training of his surgical teams in state-of-the-art procedures at each of the centers.