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Patients are justifiably concerned about how much their initial consultation, additional office visits and any surgery will cost. |
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A brief word about how our fees are determined is certainly in order. Plastic Surgery Associates of Tidewater, Inc. deals with over one hundred different insurance companies. We have tracked our fees and insurance reimbursements from year to year. Our fees are based on an extensive experience, and represent the usual and customary for this geographic area. Occasionally, a patient will state, "I know someone who had this done and it only cost . . . ." We cannot control what other physicians charge. They may offer cut rates in order to attract more patients. In our office you are paying for the expertise earned through twelve - sixteen years of post graduate education, including sub-specialty fellowship training, as well as experience practicing in the Tidewater area of Virginia, and throughout the world as a leader in Operation Smile International since the mid 1980's. With most functional surgery we can give you an idea of the cost of surgery, but not an exact fee for the proposed operation. This is because the fee is contingent on the size of the lesion being removed, whether it is benign or malignant - which will only become apparent after the analysis by pathology - and the extent of the reconstruction required. In most cases, functional surgery should be covered by your insurance carrier and your liability for payment limited to co-pays, cost shares, and deductibles. Cosmetic surgery is not covered by insurance carriers. In most of these instances we can give you an exact fee for the proposed procedures. In addition, because of our long term association with local medical facilities we can offer package rates on most cosmetic surgery, which includes a set fee for anesthesia and hospital costs as well as surgical fees. Once again you may shop around and find someone willing to do your surgery for less, but as your mother used to say, "you get what you pay for."
Financing: Sometimes surgery will include a portion which is considered functional and another portion which is considered cosmetic. In these instances we will try to secure the necessary authorization from your insurance carrier for the functional portion. You are responsible for co-pays, cost shares, and/or deductibles which apply to the functional part of the procedure, as well as fees for the cosmetic portion. As a general rule, however, operations with combined functional and cosmetic aspects can result in lower overall costs to the patient.
The world of health care insurance is rapidly, even daily, changing. We are trying hard to keep up with the multitude of changes. We deal with over one hundred different insurance carriers each with its own set of rules, regulations, and restrictions. Criteria for coverage varies from insurance company to insurance company, and can even vary tremendously depending on the type of policy within a given company. The following information applies to insurance carriers in general and may not address your specific situation. 1. Today's
Visit: If your insurance carrier still allows you to choose your own physician, even your own specialist, you are fortunate. In this case you probably do not need any referral from your Primary Care Physician (PCP) in order to have today's visit covered by your insurance carrier. Almost all managed health care systems, on the other hand, require you to see your PCP first and receive a referral for today's visit. There are some things which you must know about this referral:
2. Co-pays, Cost Shares, and Deductibles: Co-pays, cost shares, and deductibles may be a part of your insurance policy. These are your obligation to which you have agreed by choosing your particular carrier. Please understand that we are legally bound to collect these fees when applicable. We cannot under any circumstance write them off for anyone, not even for our mothers!!!
3. Participating vs non-Participating: We deal with over one hundred different insurance policies. With most we are "participating". This means we agree to accept that particular carrier's payment, along with any co-pay, cost share, or deductible required by the policy, as payment in full for our service. Any part of our fees which fall above this amount are automatically written off. In this circumstance you should not be balanced billed and are obligated only to pay the appropriate co-pay, cost share, and/or deductible. Our relationship with some carriers is "non-participating." In these instances we can treat the patients, but do not have a prearranged agreement to accept the carrier's allowed amount as payment in full and we are required to balance bill the patient. Insurance carriers on occasion have allowed balances to be adjusted. Any decision to write off part of the fee after insurance payment is subject to these constraints and up to the discretion of your physician. In these circumstances we are once again obligated by law to collect co-pays, cost shares, and deductibles
4. Functional vs Cosmetic: The criteria for functional vs cosmetic surgery are determined by each insurance carrier. The requirements for surgery to be covered can therefore vary tremendously. Your carrier should have guidelines they will give you for a specific procedure. However, the best way to know if surgery will be covered is to obtain a pre-authorization.
5. Pre-authorization for Surgery: Occasionally the pre-authorization for your surgery can be obtained over the phone by your Patient Counselor. In most instances forms must be filled out and/or a letter sent to your carrier. This letter will describe your medical history, symptoms and the indications for surgery. The appropriate ICD-9 codes will usually be included. Finally the letter will also contain a description of the proposed procedure(s) with the appropriate CPT codes. Your carrier may also require photographs, letters from referring physicians, and laboratory test results (e.g. EMG, Visual Fields, etc.). Receiving an answer back from your insurance company may take as little as 3-4 weeks or, in a few cases, as much as 3-4 months. Sometimes additional information will be requested which delays the process. If authorization for your surgery is denied, the matter can usually be appealed. We have found over the years that, following an initial denial, patients who become personally involved in the pre-authorization process have the best chance of ultimate success. From time to time a patient will say, "I heard that if you'll just word the letter a certain way they will cover my operation." Rest assured, after many years of dealing with insurance companies we have learned how best to be your advocate. We will do everything which is honest to see that you receive the benefits to which you are entitled under your insurance plan. When pre-authorization is received we can then proceed with your surgery. If authorization is ultimately denied then you must decide if you wish to go ahead and pay yourself to have the procedure done.
6. Miscellaneous Considerations: As noted above this brief review of insurance matters cannot possibly address all the fine nuances of the rapidly changing world of health care insurance. A few other miscellaneous items may however be of help.
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phone 757.673.6000 |
Plastic Surgery Associates of Tidewater, Inc. |