Topic: PAYMENT UPFRONT FOR PS

I paid nothing upfront - my insurance covered everything because my reconstruction was done immediately after my mx. My breast surgeon was in my HMO insurance plan at that time and the PS accepted whatever Aetna paid him without back-billing me the difference. I switched to a new insurance company the following year (a PPO which paid out-of-network doctors) - and my new PS agreed to accept whatever the insurance company paid him without backbilling me. Hope this info helps.

bonniejean ~ Just be sure you use a plastic surgeon who is very experienced in breast reconstruction for breast cancer -- not one who does primarily breast augmentation, face lifts, and similar aesthetic (only) surgery.  I think if you were to go to one of the larger cancer centers (MSK, for example), you would not run into this situation -- at least, I found that difference between the plastic surgeons in my immediate area (most of whom do not even take insurance) and the plastic surgeons @ UCLA, where they do way more reconstruction specifically for breast cancer.    Deanna 

Wow! I had no idea there were plastic surgeons refusing to work with insurance for breast recon. I know some recon surgeons want some payment up front, but this may be to make sure that the deductible is at least covered. There's no way many people could afford this without insurance coverage. The docs in NOLA do accept insurance, I know that.

Well I don't know if it my state or my insurance but reconstruction is covered by my insurance and it is necessary.   It should be up to the individual if they want it or not.  I'm not sure if I want it, but I want to make the decision not some PS who decides $ over mental health.

Im also in NY and used a major cancer center, msk.  I haven't paid a penny out of pocket.  Plastic surgeon is part of this hospital.  I would not use a ps who wants money up front if you are insured.  Especially being in NY, you should not have an ounce of trouble finding a reputable ps in your insurance plan

There are excellent, experienced microsurgeons specializing in all the flap procedures, including DIEP, SGAP, TUG, etc. who not only "work with insurance" but are actually CONTRACTED WITH insurance companies.

The difference is that when they "work with" insurance companies - they do some of the leg work to get the maximum benefit for you from the insurance company, but still balance bill all or part of what insurance doesn't cover. If they are contracted with an insurance company, they accept the insurance company's payment as full payment and do not balance bill. You only owe your deductible, if any. There is a huge difference. Don't be fooled by the phrasing. It is deliberate and sneaky.

To find the surgeons who do accept insurance (as full payment) you will need to look around. Some of them are at the academic centers, some are part academic and part private practice. Many of them are equal in skill to the private centers. That's right folks I dared to say it. You don't have to pay the extra money some places charge to get results as good as those places.

All insurance companies are required by law to pay for breast reconstruction. If you have insurance your reconstruction will be paid for.

Whether you choose to use a surgeon who is contracted with your insurance company or not, is up to you. If you go outside the insurance contract, the surgeon may or may not accept the insurance payment as full payment.

There are DIEP surgeons, and surgeons who specialize in the other micro techniques, SGAP, TUG, etc. who are in network for many insurance plans. There are some great, experienced, excellent plastic surgeons who will accept your insurance. Check the academic centers for alternatives to the high-priced private centers. You can achieve aesthetic results that are equal to those places without paying more. Do your homework and be clear about your goals. Ask a lot of questions.

I'm in NJ and although my PS was out of network with my insurance, he agreed to negotiate with my insurance and he took the in network rates, so with the exception of the initial consult and usual co-pays I didn't have to pay anything upfront.

I have relatively good insurance but I happen to live in an area where reconstruction is done primarily by ps who usually do cosmetic surgery.. They usually don't have to (and usually won't) get involved with insurance companies.. So I paid for my reconstruction up front  $5,500 for the TE and then another $4,500 for final replacement of TE with silicone implants and areola reconstruction.  Yes it is a lot of money, and yes it is difficult to have at your fingertips.. I must say though that my insurance company did reimburse me after I gave them copies of the surgical notes.  Mind you they paid the rate that their company had determined to be "going rates" and so I believe I ended up paying a bit less than 1/2 myself.  The laws are in place for us to have reconstruction and they are upheld but that doesn't mean they (the powers that be within the medical establishment as well as the insurance industry) are going to make it easy for us. 

I knew going in that in order to get the "best doctor" for the job I would have to set aside the costs factor and reframe it in my mind as if it was something else in life I might need desperately.. a new roof so that my equity in my home was assured not to mention my warmth etc <grin> ,a car if my old one went amuck and of course I still needed to get to work, well you get the idea.  I took out a loan.  It was imporant to me to have the reconstruction (I am aware it isn't always important for everyone) so I took it out of the hands of the insurance company so that left me with many more options - options I wouldn't have been able to use if I stuck within the guidlines of my "policy".  I do believe that we must take back that power - I know that money is tight for everyone and I know that many wouldn't be able to get a loan (a loan by the way that I paid back with my insurance many months later - at least the part they were responsible for - but I have since made the payment a priority and paid if all off).

Too many times we put our health, both physical as well as mental, in the hands of someone we have never even met!  I am a strong proponent of taking things into my own hands and yes that means prioritizing things that have value to me as apposed to something I can live without.  I felt I couldn't live without reconstruction and then went forward from their!  That did mean I had to study the laws and make sure my insurance company was forced to pay the piece of this that was their responsibility.. 

I am grateful of having the retirement money that I set aside available for me to use, to borrow against so I could move forward and hopefully one day live a better life..  I can do without the new cars and I will repair my 30 year old roof rather than replace it but I have new silicone breasts that help me cope with my incredible loss and they are worth every penny!  Good luck to all of you who might be in such a dilema as we speak.. 

I am scheduled for reconstruction in April 2010 - with an out of network surgeon (at an in network facility).  I have gotten a network gap exception approval from my insurance company and my surgeon's office says I am only on the hook for the in network deductible/out of pocket maximum (not the out of network max).  No fee up front.  However, I am still worried that there might be surprises at the end.  Is it acceptable to ask for something in writing (however, the office has already indicated they do not calculate the costs up front - only after the fact).  Any advice?

(Disclosure - I work for one of the reconstructive practices in the south.)  There are practices who do not require payment up front.  Just keep calling around. Most experienced practices know about exceptions and will give you a clear idea of your "worst case scenario" i.e. what your out of pocket would be for services.  You'll find quite a few will match your in-network benefits - Just ask for it!!)  Good luck with your search......

Sweatyspice-- my PS at NYU was out of network but "uses his botox patients to subsidize breast reconstruction patients" (I'll PM you to see if we have the same PS -- but maybe it's what they all do at NYU).  He has never charged me anything -- my insurance paid a fraction of his bills, but he writes the rest off -- I didn't even pay office visit co-pays.  What I did have to pay upfront was the deductible for the hospital ($200) -- what I had to pay after-the-fact was additional hospital bills and anesthesia bills -- in-network, but covered at less than 100%.