Covering “borderline” or “grey area” procedures is a constant struggle in plastic surgery billing. Certain insurance companies do certain things. Lines are blurred. Rules are changed. The landscape is ever-changing. Even if you can get something covered, who the heck knows what you’ll be paid…certainly not what you would charge self-pay right?
Enter lipedema, a condition that impacts 1 in 100 women. Previously considered “experimental” or “excluded,” major insurance carriers are now covering treatment for lipedema surgery.
No, no, not out of the kindness of their hearts…someone (many someones) had to sue them. That said, the landscape has yet again changed.
Pioneering this change is a team passionate about helping patients. This organization was founded by a former major law firm partner and payment/coverage attorney whose grandmother lived with lipedema. Witnessing the impact firsthand fostered passion, which served as the inspiration for CoverLipedema. The group has been instrumental in getting insurers to cover and pay surgeons fairly for surgery as they have help hundreds of women with lipedema.
So…we’ve stolen some great tidbits from the CoverLipedema Team to crystallize the opportunity if you’re considering expanding your practice verticals or encountering patients in need of the service. Without further ado…
- Who covers it? Aetna, Anthem BCBS, Cigna, UHC all recently settled (the aforementioned suit that led them to the light) and issued coverage policies to provide care when there is no network surgeon offering the services. Other major payers also provide coverage (e.g., non-Anthem BCBS) to avoid said suits.
- What body areas/services are covered? Insurers cover liposuction on the limbs, hips, and buttocks as well as all skin excisions and even panniculectomy for lipedema in the abdomen.
- What is the reimbursement like? Network surgeons have been able to “carve out” contract pricing and non-network surgeons have done dozens of single case agreements that cover a series of staged surgeries with professional fees over $50,000.
- Anything else I should know? Insurers will cover overnight hospital stays for larger volume liposuction.
- So, how does the CoverLipedema Team do it and why don’t we at Auctus go it alone (and why can’t the other BillCos do it)? First and foremost, CoverLipedema has extensive high-level connections with insurers, employers, and regulators. They’ve also got the experience of pushing hundreds of cases. We at Auctus work closely with their team to facilitate the billing, while they put their experience to work to get physicians appropriately compensated and patients covered. We do our part. They do theirs. You get the best of all worlds
- What exactly does the CoverLipedema Team do? They help patients submit prior authorizations for surgery, negotiate single case agreements, win appeals, and get network exceptions. This allows the surgeons to do what they do best – treat the patients.
- How do I get started? In a word, slowly. Work with your team to ensure you start with patients who larger self-funded plans to establish a fair rate. Once a fair rate is established with an insurer, they tend to stick to keeping the same rates for other patients.
This is not for everyone. It is not billing for lumps and bumps. That said, if you want to explore serving a community who is always grateful for the care and will achieve life-changing impact upon treatment…we can help
For more information, give us a call: