Insurance and Cost
Talking to Your Insurance Company | Insurance companies cover costs related to medical treatment that the patient would not ordinarily be able to afford or negotiate. Medical necessity must be proven in order to receive benefits. Reconstructive procedures restore normal structure or correct a functional deficit. These procedures are considered medically necessary. Most reconstructive procedures are financed by insurance policies. However, since insurance plans rarely cover 100% of medical expenses, you should expect to share some of the financial responsibility. |
Talking to Your Insurance Company
Your medical insurance is a contract between you and the providers of the coverage. This includes your employer and the insurance company. Our office communicates with your insurance company when necessary. However, it is ultimately your responsibility to understand the benefits and exclusions in your policy. We want to help you understand your coverage. Coverage and benefits are dependent on the type of policy you have. It is imperative that you understand the differences between the types of plans available when choosing insurance for you and your family.
When calling your insurance company, you should always record the date of the call and the name of the person helping you. The insurance company may log your call in its system. Insurance representatives can tell you what your benefits are but often, they do not disclose contractual limitations. You should tell them why you are calling so that they can give you all of the information that is available to them.
Contractual limitations or "exclusions" are items documented in the policy for which coverage is denied. For example, most medical policies deny coverage for dental procedures unless they are related to a specific instance, as stated in the policy. Some policies state that they do not cover treatment for congenital birth defects after the age of nineteen. Exclusions are not based on medical necessity. They are simply clauses stating exactly which treatments are not covered. It is possible to bypass an exclusion by changing your insurance plan or by petitioning your employer to override the particular exclusion.
If coverage of a procedure is questionable, a "predetermination of benefits" may be necessary. This is the process of submitting all information regarding the patient's health and proposed treatment to the insurance company for review. The insurance company assesses the medical necessity of the case and evaluates contractual limitations that would prevent treatment from being covered. This is a lengthy process but is a way of confirming your responsibility prior to initiation of treatment. "Pre-certification" may also be required before initiation of treatment. The insurance company is notified that you are planning to undergo specific treatment. Insurance companies review certain cases prior to treatment to ensure medical necessity and coverage by the policy. If pre-certification is not obtained prior to treatment, the insurance company may penalize or deny reimbursement. Our office usually obtains pre-certification for surgery. If we experience difficulties, we will contact you and request your assistance.
A "claim" refers to the charges for services rendered. Most claims from our office are submitted electronically. Claims are often reviewed for medical necessity by the insurance company, even if the surgery has been pre-certified. Additional information is often requested from both the provider and patient. We supply all necessary information as soon as possible and expect the same response from the insured. Sometimes claims are delayed for unclear reasons and require frequent telephone calls to the insurance company to obtain payment.
back to top
Your medical insurance is a contract between you and the providers of the coverage. This includes your employer and the insurance company. Our office communicates with your insurance company when necessary. However, it is ultimately your responsibility to understand the benefits and exclusions in your policy. We want to help you understand your coverage. Coverage and benefits are dependent on the type of policy you have. It is imperative that you understand the differences between the types of plans available when choosing insurance for you and your family.
When calling your insurance company, you should always record the date of the call and the name of the person helping you. The insurance company may log your call in its system. Insurance representatives can tell you what your benefits are but often, they do not disclose contractual limitations. You should tell them why you are calling so that they can give you all of the information that is available to them.
Contractual limitations or "exclusions" are items documented in the policy for which coverage is denied. For example, most medical policies deny coverage for dental procedures unless they are related to a specific instance, as stated in the policy. Some policies state that they do not cover treatment for congenital birth defects after the age of nineteen. Exclusions are not based on medical necessity. They are simply clauses stating exactly which treatments are not covered. It is possible to bypass an exclusion by changing your insurance plan or by petitioning your employer to override the particular exclusion.
If coverage of a procedure is questionable, a "predetermination of benefits" may be necessary. This is the process of submitting all information regarding the patient's health and proposed treatment to the insurance company for review. The insurance company assesses the medical necessity of the case and evaluates contractual limitations that would prevent treatment from being covered. This is a lengthy process but is a way of confirming your responsibility prior to initiation of treatment. "Pre-certification" may also be required before initiation of treatment. The insurance company is notified that you are planning to undergo specific treatment. Insurance companies review certain cases prior to treatment to ensure medical necessity and coverage by the policy. If pre-certification is not obtained prior to treatment, the insurance company may penalize or deny reimbursement. Our office usually obtains pre-certification for surgery. If we experience difficulties, we will contact you and request your assistance.
A "claim" refers to the charges for services rendered. Most claims from our office are submitted electronically. Claims are often reviewed for medical necessity by the insurance company, even if the surgery has been pre-certified. Additional information is often requested from both the provider and patient. We supply all necessary information as soon as possible and expect the same response from the insured. Sometimes claims are delayed for unclear reasons and require frequent telephone calls to the insurance company to obtain payment.
back to top
Alternative Forms of Insurance
Although our doctors treat patients from all over the world, we are only equipped to accommodate insurance coverage from the United States. Within the United States itself, there are many types of medical insurance plans offered through private insurance companies, state and federal agencies, and public assistance programs.
Our doctors are on a variety of insurance plans. We try to diversify their involvement to compensate for the ever-changing insurance industry and to accommodate our patients. As such, we accept various private medical insurance as well as some public assisted programs. Proper authorization must be obtained if required.
Medical coverage on automobile insurance policies covers some medical expenses but it is not accepted by our office. We also do not render treatment with the expectation of payment from a pending lawsuit. We must be able to cover the expenses of treatment. Neither automobile policies nor pending lawsuits fulfill that requirement. Our office does not accept workers' compensation cases.
back to top
Although our doctors treat patients from all over the world, we are only equipped to accommodate insurance coverage from the United States. Within the United States itself, there are many types of medical insurance plans offered through private insurance companies, state and federal agencies, and public assistance programs.
Our doctors are on a variety of insurance plans. We try to diversify their involvement to compensate for the ever-changing insurance industry and to accommodate our patients. As such, we accept various private medical insurance as well as some public assisted programs. Proper authorization must be obtained if required.
Medical coverage on automobile insurance policies covers some medical expenses but it is not accepted by our office. We also do not render treatment with the expectation of payment from a pending lawsuit. We must be able to cover the expenses of treatment. Neither automobile policies nor pending lawsuits fulfill that requirement. Our office does not accept workers' compensation cases.
back to top
Differences between HMO's and PPO's
There are many types of medical insurance policies. These plans are defined by the type of coverage offered and how you obtain treatment. The basic types of plans are PPO's, HMO's, POS and indemnity plans.
PPO plans offer in-network as well as out-of-network levels of benefits. The patient can seek treatment from any provider. The insured is responsible for a co-payment for office visits and co-insurance for other treatment. An example of a PPO plan would be a plan is one that provides 90% coverage as long as you stay in the given network of providers. This level of benefits may be immediate or may begin after a deductible $250 is met. Then the insured is responsible for the 10% up to an amount of their out-of-pocket expense which might be $1,250 including the deductible. The insured in this example would be responsible for $1,250 plus any procedures not covered by the policy. The same plan may decrease to 70% coverage after a $500 deductible amount is paid up to the out-of-pocket expense of $1,750 if you go outside the given network of providers. The insured in this instance would be responsible for their co-insurance of $1,750 as well as the difference between the billed amount by the provider and the allowed amount by the insurance company.
HMO plans only offer in-network benefits. Therefore, the patient must stay within a network of providers to receive benefits. These plans require that the insured select primary care physicians (PCP) to coordinate treatment. If the patient wants to see a specialist, then they must contact their PCP for a referral. A referral is proper authorization to see the specialist and must be approved by the insurance company. In most cases, the specialist must be a contracted provider in order for the referral to be approved. The patient is usually responsible for a co-payment for office visits. All other treatment is fully covered (100%) with proper authorization.
POS plans combine the attributes of both PPO plans and HMO plans. Each insurance company that offers a POS plan has certain guidelines. An example of a POS plan is one in which the insured and family chooses a PCP. Referrals are suggested, but the patient has an out-of-network benefit in the event that the referral is not approved. The level of benefit is usually higher with the referral, regardless of whether the specialist is in-network or not.
Indemnity plans have no defined provider network. The benefits are based on a percentage of the allowed amount. Usually these plans cover 80% of the usual and customary rates (UCR). The insurance company will simply pay 80% of what it considers reasonable. The insured is responsible for their 20% co-insurance plus any difference between the UCR and the amount billed.
back to top
There are many types of medical insurance policies. These plans are defined by the type of coverage offered and how you obtain treatment. The basic types of plans are PPO's, HMO's, POS and indemnity plans.
PPO plans offer in-network as well as out-of-network levels of benefits. The patient can seek treatment from any provider. The insured is responsible for a co-payment for office visits and co-insurance for other treatment. An example of a PPO plan would be a plan is one that provides 90% coverage as long as you stay in the given network of providers. This level of benefits may be immediate or may begin after a deductible $250 is met. Then the insured is responsible for the 10% up to an amount of their out-of-pocket expense which might be $1,250 including the deductible. The insured in this example would be responsible for $1,250 plus any procedures not covered by the policy. The same plan may decrease to 70% coverage after a $500 deductible amount is paid up to the out-of-pocket expense of $1,750 if you go outside the given network of providers. The insured in this instance would be responsible for their co-insurance of $1,750 as well as the difference between the billed amount by the provider and the allowed amount by the insurance company.
HMO plans only offer in-network benefits. Therefore, the patient must stay within a network of providers to receive benefits. These plans require that the insured select primary care physicians (PCP) to coordinate treatment. If the patient wants to see a specialist, then they must contact their PCP for a referral. A referral is proper authorization to see the specialist and must be approved by the insurance company. In most cases, the specialist must be a contracted provider in order for the referral to be approved. The patient is usually responsible for a co-payment for office visits. All other treatment is fully covered (100%) with proper authorization.
POS plans combine the attributes of both PPO plans and HMO plans. Each insurance company that offers a POS plan has certain guidelines. An example of a POS plan is one in which the insured and family chooses a PCP. Referrals are suggested, but the patient has an out-of-network benefit in the event that the referral is not approved. The level of benefit is usually higher with the referral, regardless of whether the specialist is in-network or not.
Indemnity plans have no defined provider network. The benefits are based on a percentage of the allowed amount. Usually these plans cover 80% of the usual and customary rates (UCR). The insurance company will simply pay 80% of what it considers reasonable. The insured is responsible for their 20% co-insurance plus any difference between the UCR and the amount billed.
back to top
Cost of Craniofacial Surgery
Craniofacial surgery costs vary depending on the procedures performed, the providers involved and the patient's individual circumstances. Today, with the involvement of insurance companies, the costs to the patient can be minimal. This depends largely on the insurance company supplying the coverage.
Our office is happy to discuss potential situations or estimate costs for individual cases at any time. Please feel free to contact us at ins@craniofacial.net .
back to top
Craniofacial surgery costs vary depending on the procedures performed, the providers involved and the patient's individual circumstances. Today, with the involvement of insurance companies, the costs to the patient can be minimal. This depends largely on the insurance company supplying the coverage.
Our office is happy to discuss potential situations or estimate costs for individual cases at any time. Please feel free to contact us at ins@craniofacial.net .
back to top
Take Political Action about Coverage
Coalition for Insurance Coverage of Children's Deformities
In 1997, Dr. Kenneth Salyer, along with other members of the American Society of Plastic Surgery and their Government Relations committee, founded a coalition to address the issues of insurance denials for treatment of children's deformities and congenital defects. Coverage was being denied on the basis that such surgeries were deemed cosmetic. In 1998, a children's deformities bill was introduced into legislation on a state and national level.
In Texas, Dr. Salyer led the charge for the ASPS, and the Texas Society of Plastic Surgeons, in bringing this issue to the attention of our legislators. State Senator John Carona and State Representative Leticia Van de Putte sponsored the bill that was signed into law by Gov. George Bush in June 1999.
The bill states that "a heath benefit plan that provides benefits to a child who is younger than 18 years of age must define reconstructive surgery for craniofacial abnormalites under the plan to mean surgery to improve the function of, or attempt to create a normal appearance of, an abnormal structure caused by congenital defects, developmental deformities, trauma, tumors, infections, or disease." This bill will affect the implementation of any health insurance written or delivered after January 1, 2000.
On a national level, Senator John McCain, along with Sen. Olympia Snowe, introduced the Treatment of Children's Deformities Act into the Senate. The Hon. Sue W. Kelly of New York introduced it into the House of Representatives. The actor Stacy Keach, who was born with a cleft lip, has also joined the coalition to support the passage of this Act on a national level. He has been interviewed on radio and television promoting awareness of the importance of this bill and the positive impact it will have for the children.
To become involved with this important legislation, or for more information, please go to the coalition page on plasticsurgery.org .
back to top
Coalition for Insurance Coverage of Children's Deformities
In 1997, Dr. Kenneth Salyer, along with other members of the American Society of Plastic Surgery and their Government Relations committee, founded a coalition to address the issues of insurance denials for treatment of children's deformities and congenital defects. Coverage was being denied on the basis that such surgeries were deemed cosmetic. In 1998, a children's deformities bill was introduced into legislation on a state and national level.
In Texas, Dr. Salyer led the charge for the ASPS, and the Texas Society of Plastic Surgeons, in bringing this issue to the attention of our legislators. State Senator John Carona and State Representative Leticia Van de Putte sponsored the bill that was signed into law by Gov. George Bush in June 1999.
The bill states that "a heath benefit plan that provides benefits to a child who is younger than 18 years of age must define reconstructive surgery for craniofacial abnormalites under the plan to mean surgery to improve the function of, or attempt to create a normal appearance of, an abnormal structure caused by congenital defects, developmental deformities, trauma, tumors, infections, or disease." This bill will affect the implementation of any health insurance written or delivered after January 1, 2000.
On a national level, Senator John McCain, along with Sen. Olympia Snowe, introduced the Treatment of Children's Deformities Act into the Senate. The Hon. Sue W. Kelly of New York introduced it into the House of Representatives. The actor Stacy Keach, who was born with a cleft lip, has also joined the coalition to support the passage of this Act on a national level. He has been interviewed on radio and television promoting awareness of the importance of this bill and the positive impact it will have for the children.
To become involved with this important legislation, or for more information, please go to the coalition page on plasticsurgery.org .
back to top