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Insurance Predetermination For Plastic Surgery Procedures

Patients frequently consult plastic surgeons for medical procedures and conditions that they may feel are covered or should be covered by their health insurance. Sometimes this is true, sometimes not. Procedures such as breast reduction (women and men), abdominal panniculectomy after weight loss, and rhinoplasty (nose surgery) are common health insurance requests by patients. It is also a plastic surgery procedure that is highly scrutinized by medical insurance and a very specific list of eligibility criteria exists where it may be considered medically necessary or cosmetic in nature. It is not up to the plastic surgeon or the patient to determine whether such a procedure is covered. That is determined by your health insurance through a process known as pre-determination. This must be done before the procedure is carried out or it will be automatically rejected even though it may be eligible for coverage.

Prior determination by the health insurance company is necessary for selected inpatient and outpatient medical services (including surgery, major diagnostic procedures and referrals) to determine if they are medically necessary. It is fair to say that all plastic surgery procedures must be determined in advance. Health insurance generally assumes that if a plastic surgeon performs a procedure it must be ‘cosmetic’ in nature. This is the process where your plastic surgeon writes a letter to your health insurance company giving them the diagnosis, any supporting information that proves the problem is causing the medical symptoms, and the operation needed to fix the medical problem. The main thing here is that there must be medical symptoms such as pain, recurring skin problems, or difficulty breathing for example. Just because it looks bad or is caused by an accident or birth defect is not enough. (I didn’t make the rules, I just had to follow them) Waiting for a response from this letter from your insurance company will take at least 30 days after it was sent. It’s not a quick process so plan accordingly. Appearing at your plastic surgeon’s office on December 10th for the insurance procedure you want to do before the end of the year will not work. There is not enough time to set it up in advance.

For a member to receive benefits for a plastic surgery procedure, it must be authorized or “certified” before it is provided. Precertification, often used interchangeably with predetermination, is part two of the process. Precertification can help avoid unnecessary charges or penalties by ensuring your plastic surgery care is performed at an appropriate network facility and by a network provider. Predetermination and Precertication work together. Precertification is a faster process that can be determined over the phone or by fax between the plastic surgeon’s office and the health insurance company.

Therefore, pre-certification includes a review of both services and settings. Medical care is covered according to plan benefits…not what you think should be covered or how you think it should be done. Health insurance is essentially a business contract not a set of ethical or moral guidelines. Many services require you to use a provider designated by the health insurance provider list. For benefits to be paid, not only are you eligible for benefits but the services must be covered benefits under the contract at the time the surgery is performed.

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