Q: I am a 24 year old interested in a breast reduction. I am looking to see if my insurance can pay for part or all of the procedure but I know that the surgeon will have to fill out a particular form and then submit it to my insurance and then the insurance will deny or accept the form. Please let me know if there is any way you can help me with this. Thank you for your time, Alice
A: Alice, many thanks for contacting us. Having practiced plastic surgery for over twenty years, I’ve done many hundreds of breast reductions. The vast majority are very happy and have great results. For most of those years, we proceeded as you suggest: Patients would come to my office for an initial appointment. We would carefully and thoroughly evaluate them to understand the burden they were bearing. We learned how their large, heavy, and in some cases massively disproportional gigantic low hanging breasts were causing inescapable back, neck, and shoulder pain, postural backache, rashes beneath the breasts, and how their ability to exercise and live a normal life was impaired. We heard repeatedly about how no bra offered adequate support without straps pulling forward on their shoulders and digging painfully into their skin. We meticulously recorded this information, and researched their particular insurance plan criteria for reduction mammaplasty coverage. After hours, I sat at my desk dictating and then editing a letter with diagnosis and procedure codes, then printing on letterhead and sending to the insurance company for pre-authorization. Often, despite inordinate suffering of the patient, insurance denied the procedure. Sometimes, patients would appeal their decision (in at least one case visiting the insurance office in Glendale, CA and taking off her shirt to show utilization review staff her situation), and sometimes, they accepted the insurance company denial and continue living in misery. Sometimes, I appealed adverse decisions on behalf of patients with a second letter. Sometimes, the reduction was approved, and we did the operation (YAYYY, happiness !!!). Once approved, breast reduction patients make another visit to my office to review the procedure in detail, explain size and location of expected scars, both the lift and the reduction component, post-surgical scar management-minimization protocol, and answer all questions before scheduling the day of surgery. This helps prepare patients in advance, so they know what to expect. Also, I get to understand better exactly what each woman wants so I can plan the procedure to meet her needs.
As you may know, the breast reduction procedure involves pre-surgical marking and precision design. My goals are always twofold: Relief of pain and lifestyle improvement, PLUS creation of beautiful feminine breasts. The operation itself is accomplished at hospital or surgery center and for me, is several hours of intense concentration and decision making. I have one chance to get it right for each patient, and rise to the demands of the moment, mobilizing all of my many years of preparation and practice to safely and artistically produce the best, most feminine breast in terms of shape, size, and projection for each and every woman who has trusted me with this vital element of her femininity.
After completion of the surgery, I’m drained, but carefully and happily apply pads a post surgical bra, confident that I’ve gifted the woman with new comfort and beauty. I write orders, dictate a procedure note, call her family or significant other to reassure them that their beloved wife, daughter, or mother did well, and will be ready to go home after one to two hours in recovery room. I write post surgical care instructions, give the patient’s family my office phone, pager, and cell phone number to call me if any problems or questions arise, write prescriptions for analgesics and anything else the patient may need, and then go on to the rest of my work day. When my dictated report comes back to the office (this happens when I log on to hospital computer system and sign the report), I look up her diagnostic and treatment codes and complete a standard form which is submitted with the operative report and insurance pre-approval form to my billing service, which charges me 7% of total collections to bill the insurance company for the procedure they pre-approved. My billing service uses a book of nationally standardized fees for medical procedures to calculate our bill from the breast reduction procedure codes I’ve provided for them.
I go on with the rest of my busy practice, but will see each patient 2-3 days after the procedure in the office to examine the result and make sure all is well, change bandages, supply the patient with pads and a second bra if needed. She will see me a week later, then two weeks later, then a month later, and then perhaps three months later as all settles and continues to heal. At each visit, we enter the next stage of scar management with taping, support, silicone sheeting on the scar, etc. Of course, I may see her more frequently to manage any issues or problems that arise, but this is not common.
Eventually, usually several weeks after the breast reduction, I’ll find a letter from her insurance company in my mail. About half the time, it’s a denial of payment because of some technicality or manufactured excuse. Then, my billing company needs to respond (or I need to respond) with more information or whatever they want. Usually Alice, after some months go by, I get a check from the insurance company. The check helps me pay my office rent, my staff’s salaries, my medical equipment and supplies, my telephone bill, electric bill, continuing medical education and plastic surgery society dues, my office cleaning service, my taxes and fees for certification and accreditation, my insurance, the billing service, and the endless other high expenses of running a surgical practice. My bill for breast reduction, I know from past experience, is usually about nine thousand and some dollars. But guess what Alice… The insurance company has their own way of processing my charges. They’ve entered my submitted information into their computers, which based on a variety of factors, comes up with an “adjustment” to my fees. Based on your insurance plan, your deductible and co-pay, the procedure performed, the geographic area I practice in, prevailing regulatory statutes, contracts, their profit targets, and many other pieces of data, the adjustment is about $7500-$8500 down from the $9000 or so that I’ve billed. If I’m super lucky, I’ll get $1500 to cover all of the expenses I’ve incurred in performing the procedure. Often Alice, the payment is closer to $750 or $800, and sometimes, $500 or less. It’s because of these adjustments that for many years, I was forced to work sixteen hours a day or more each and every day just to pay my bills and stay in business. Recently, because I’ve not been able to spend enough time with my family for years or take care of myself or enjoy living, I decided that I can’t work through insurance companies any more. In the end, because of the cost to me of doing these procedures (maintaining an office and practice), their adjustments have been forcing me to pay a large portion of each and every surgery that I do. I cannot afford to do this any more.
I’m sure that you and/or your significant other have been paying your insurance premiums, and that you would not at age 24 be seeking breast reduction unless you desperately need it. I understand you don’t want surgery, but have concluded after years of suffering that there’s perhaps no alternative. Breast reduction is a reconstructive procedure, performed to relieve disabling problems, and to offer some relief from your constant aching back, neck, and shoulder pain and from the cumbersome burden of your large heavy breasts. Breast Reduction is NOT cosmetic surgery, and should be a covered procedure. You are entitled to have it, and to the best possible result. You’ll be living with your result for your entire life.
Find a surgeon on your insurance plan who will do it, like I did for twenty years. If you cannot, I will be glad to see you, but we only accept payment in advance for the procedure, and Jennifer can tell you how much it costs 858-295-4001. Financing is available.
Many thanks Alice, Best Wishes, Steve Laverson, MD