Top 5 Things a Breast Reconstruction Patient Should Know/Do About Their Insurance  Coverage:

December 13, 2022
by Admin

1. Women’s Health Rights and Cancer Act – you are protected folks.  This is a Federal Mandate.  So all the games insurance companies play hold even less water here.  You are protected for reconstruction (or not) at ALL STAGES including the contralateral breast.  The language of the mandate doesn’t answer every question or address every situation, but the message/intent/protection is clear…YOU are protected. 

2. You have options – Your reconstructive method and timing are clinical and personal decisions.  Insurance companies cannot dictate the steps you take on your journey.  They don’t get to decide when reconstruction is over.  They don’t get to dictate method of reconstruction. They don’t get to tell you who to see…and if your desired reconstructed method doesn’t have an in-network surgeon in your area, your carrier has an obligation to provide adequate coverage.  You may hear otherwise, but you know better! 

3. In- and Out-of-Network Benefits are TWO DIFFERENT THINGS.  You may have a deductible, you may have coinsurance, you may have a copay, you may have an out-of-pocket max, you may have all these things for a facility versus professional services versus family/individual.  Know the difference.  And once you get all that down, know that IN and OON providers are two different levels of benefits that most often DO NOT overlap.  Confused yet?  We are too…and we do this for a living.  Ask for help if you need it or aren’t sure! The Auctus Line.

4. Expect bills…from lots of folks.  You’re going to see a general surgeon, a radiologist, a plastic surgeon…maybe more…at a surgery center, a hospital, a lab, etc.  Each of these different people/entities may or may NOT be part of the same group and therefore may or may NOT be on the same bill.  Be sure you know where the lines are and don’t be worried if you get several different bills.  This is normal…as long as they’re correct…which leads us to… 

5. Read your Explanation of Benefits!  Every single thing you have done by a doctor/hospital/lab etc. (AKA provider) is reduced to a five digit code. Seriously.  We’re oversimplifying but basically, yes.  Every single code/service should have a charged amount (what your provider charges the insurance company), and allowed amount (the amount the insurance company will consider as payable based on the contract they have with your provider…which you can’t see and no one can share with you because it is a contract between two business entitites technically…AKA any provider can charge whatever they want, even though they know what they’ll be paid…the rest is a “write off” or “adjustment” AKA funny money no one ever expects to pay or be paid) a paid amount (what your insurance company paid the doctor), the “patient responsibility” AKA what you owe, which should be a product of your BENEFITS (e.g., copay/coinsurance/copay).  MAKE SURE that you are being billed based on your benefits.  Not based on a bogus denial.  Not based on a bad biller.  Based on what was sent ACCURATELY to your insurance company and paid APPROPRIATELY by them.  This is where patients get taken advantage of so ASK question.  Keep an eye out for charges that have no payments applied and/or worse…no adjustments.  Keep an eye out for bills that don’t show break downs.  Keep an eye out for answers that don’t make rational sense.  This is a game to the insurance companies and it is intentionally confusing.  If it doesn’t pass the sniff test…press them.   


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