Q and A:
My most important question, I have Aetna insurance. Is a breast reduction, tummy tuck & upper arm reduction covered? In August I will be on Medicare also. I had a gastric bypass two years ago and have a lot of loose hanging skin which is not allowing me to do physical activity.
Dr. Laverson answer:
Great to hear from you Robin, and congratulations on your weight loss!!!
Because of the insurmountable obstacles that third party payers impose upon many surgeons, myself included, our office has eliminated them from the doctor-patient relationship as much as possible.
We don’t want to request permission (“pre-authorization”) from non-professionals to treat patients, we don’t want to be told what procedures we’re allowed or not allowed to do, what drugs we can and cannot prescribe, where to do our procedures, what other specialists and providers we must or must not refer to, and how much we’ll be paid for our services. Third parties who are paying for care regulate that care, and they do so without any medical license or liability. They are a for-profit business. We’re health care professionals. We don’t always agree with insurance company profit-based decisions. From a practical standpoint, insurance related paperwork and administrative responsibilities can be overwhelming.
Because I’m accountable to patients for quality and safety, I must maintain some control over the decision making process in evaluation and management. I like discussing with each patient what they believe to be best for them, and being able to implement a patient-desired plan, as you yourself have articulated (breast, tummy tuck, arms). We must deliver the type of results patients want without restrictions and burdens placed upon us by entities who don’t know us, who don’t know our patients, and who aren’t as committed as we are to the best possible result. Insurance companies, in general, commoditize your care. You’re a set of numbers to them. Your premium payments are income they try to maximize, but your care is a cost they don’t want to incur. Insurance offers baseline standard care at the least cost. The fee that most payers provide for surgical procedures doesn’t come close to covering the true cost of each procedure. If multiple procedures are performed, as you’re requesting, insurance only pays for the first one. If two sides are done (e.g., breasts, arms), insurance won’t pay for the second side. Billers must be paid, office rent, staff, equipment, supplies, insurance, and utilities must be paid to remain in practice. Although you pay your premiums, and you’re thus entitled to care, insurance reimbursement to surgeons is so paltry that after all these expenses, surgeons are not being paid for surgery, we’re actually paying for the surgery too. The arrangement is very favorable to insurance companies, and I participated in that arrangement for over twenty years. Thinking I was supporting patients, I was merely enriching third party payers, starving myself and my office, and diminishing my own capacity to continue caring for patients.
I believe patients deserve the best I can deliver. Patients are not numbers here, they’re respected human beings with hopes, dreams, and each with his or her own unique, valuable, and special identity. High quality is costly Robin. Our goals and the goals of third party payers are irreconcilable.
So, in essence Robin, if you must have these procedures covered by insurance, your next step should be to consult with plastic surgeons within your network, who accept the insurance you have. This in no way means your care will be less, or your result not as good. It just means that for insurance to pay, you must follow their rules. This means to work with their contracted specialists. I am no longer a Medicare participant. As long as you see a board certified plastic surgeon, and you trust that surgeon, your outcome will likely be just fine. You’ve already done the hardest part, and the most important part, losing your extra weight.
Don’t hesitate to contact us if questions.
Feel Beautiful Plastic Surgery
11199 Sorrento Valley Rd STE 202, San Diego, CA 92121