Showing posts with label insurance. Show all posts
Showing posts with label insurance. Show all posts

Thursday, February 17, 2011

Can You Tell Me…

Office phone rings.

PT1992, “Can you tell me how long Dr. Bates has been at that location?”

“20 years,” I reply.

PT1992, “I think you did my surgery.  One of my saline implants has burst.”

“Let me put you on hold.  I’ll look and see if you were ever our patient.”

I am acutely aware that I don’t recognize the voice or patient name, but feel I am okay with HIPAA to verify to PT1992 that indeed we once had a patient by that name.

I then as politely as I can tell her, “I will need a signed medical records release to give you any more information as I don’t know your voice and have no other way to verify whom I am speaking with.”

She seems to accept this, but then says “Can you just tell me which company made the implants?”

I repeat the above.

PT1992, “Well can you tell me what kind of coverage I might have?”

“You should be able to get free replacement implants, but if it as it has been more than 10 years that will be all the assistance you will be able to receive.”

PT1992, “Thanks.  Since I have moved away, I’ll go to the surgeon here and have them send a release.  Will that work?”

“Yes, that will work.”


Related Posts: 

It’s Happened Again (June 5, 2007)

Breast Implants -- Some History (March 3, 2008)

Silicone vs Saline Breast Implants (March 4, 2008)

Silicone Implants and Health Issues  (March 5, 2008)

Saline or Silicone? (November 18, 2010)



Mentor Enhanced Advantage Warranty

INAMED (McGhan) ConfidencePlus™ & ConfidencePlus™ Platinum Breast Implant Limited Warranties

Wednesday, November 17, 2010


Do you recall the severe rationing of food and water the Chilean miners had to endure to survive?   The rationing was done to stretch their limited resources.

I would argue the state of Arizona’s new policy to not cover organ transplants for patients on Arizona Health Care Cost Containment System (AHCCCS) or their version of Medicaid is a similar form of rationing.

AHCCCS, as many Medicaid programs, is underfunded.  They are trying to operate on a limited budget.  Something has to give.

Sadly in this case, many (NPR reports 98) had already been granted approval for organ transplants which they may not receive.  Francisco Felix, 32, who due to Hepatitis C needs a liver transplant, is reported to have made it to the operating room, prepped and ready for his life-saving liver transplant when doctors told him the state's Medicaid plan wouldn't cover the procedure.  The liver he was to receive went to someone else.

In this prolonged economic downturn, I wonder how many parents have had to tell their children who were accepted into their dream college they will not be able to go, the family income has changed and it is no longer affordable?

In a perfect world, everyone would have health insurance.  Health insurance companies (private, state, and federal) would have unlimited resources so that all “evidence-based” medically necessary care/procedures/medications would be covered.

Hell, in a perfect world, we wouldn’t need health care.

It isn’t a perfect world.  There are limited resources.  Tough decisions must be made in doing the most with the available resources.

Is this the sort of rationing of medical care we will be seeing more of in the future?

Wednesday, November 3, 2010

Know Your Surgeon

I would caution anyone who elects to have cosmetic or plastic surgery to go to a surgeon’s office.  Meet your surgeon.  Along with learning about the procedure, ask about their training.  If your procedure is to take place outside of a hospital (for example, in a surgery center), ask if your surgeon has privileges to do the procedure in a major hospital (the hospital should have checked their training when doing the credentialing).

Treat cosmetic/plastic surgery as surgery with all the benefits AND risks of non-elective surgery.

I stumbled across this article Owner of Cosmetic Surgery Clinic Sentenced in New York for Health Care Fraud.

Arthur Kissel,a/k/a "Arthur Froom," was sentenced October 25th in Manhattan federal court to 10 years in prison for healthcare fraud offenses.  Neither Kissel nor his wife Sonia LaFontaine are doctors, but they engaged in a series of fraudulent practices out of their Manhattan cosmetic surgery clinic.  (pdf file of press release from United States Attorney Southern District of New York)

LaFONTAINE and KISSEL, along with several coconspirators including doctors who worked at LRMA, engaged in four different types of fraud at the clinic:
•  LaFONTAINE performed procedures which were billed as if they had been performed by licensed physicians.
•  LRMA billed cosmetic procedures as medically necessary procedures so that health insurance companies would be duped into paying for them.
•  KISSEL and LaFONTAINE submitted claims to health insurance companies for procedures that were never performed.
•  KISSEL and LaFONTAINE exaggerated insurance claims by increasing the number and complexity of procedures.
KISSEL and LaFONTAINE were indicted in March 1998 with conspiracy to commit health care fraud. KISSEL was extradited from Canada in 2008 and pled guilty on September 4, 2009.

Kissel and LaFontaine’s practices actually led to the death of one patient:

In imposing the maximum sentence permitted by law,Judge CHIN rejected KISSEL's claims of "ignorance and dumbness"and found that he "acted out of greed." He also stated that his crimes "led directly to the death" of JOEL CUNNINGHAM, who died on January 8, 1998, while undergoing an outpatient abdominal liposuction procedure at LRMA. CUNNINGHAM had wanted to become a NYPD police officer, but was too heavy to meet the entrance standards. He decided to have a liposuction procedure at LRMA,which used extensive advertising claiming that it was operated and supervised by a "world renowned surgeon," when in fact it was operated and supervised by KISSEL and LaFONTAINE. Evidence presented at a subsequent wrongful death suit in state court indicated that Cunningham had died of complications from anesthesia, which had been administered by an LRMA anesthesiologist who was at the time on professional probation due to drug and alcohol abuse.

Wednesday, April 7, 2010

Insurance Premium Increase

Physicians aren’t exempt from the struggles with personal health insurance coverage, affordability, denied coverage, etc.   When I finished my training and opened my practice 20 years ago I had to buy individual coverage.   All options included a rider that excluded coverage on my uterus and ovaries due to fibroid surgery during training.  So when I had my TAH & BSO a few years later, the entire cost came out of my pocket.  Fortunately, I knew how to ask for cost reductions, but still…

My husband and I are both small business individuals.   I have always carried our health insurance under my name (office).  Over the years we have gone to a health savings account with a high deductible to keep the cost reasonable.  Fortunately, we have been mostly healthy.

Last month, we received a letter from Assurant Health telling us of a policy change that includes a $75 ER visit charge.  I thought this might be their way of avoiding a policy increase, but no.  Last week I received the notice regarding an increase to our policy.  Currently, our premium is $619.76 per month plus a mandatory $100 deposit into the HSA each month. 

The notice included the “good news”  -- “Congratulation!  You’re a Healthy Discount candidate.”  To determine your eligibility for the Healthy Discount, follow these simply instructions:  1.  Answer all six questions below.  Please consider the last 12 month when answering these questions……”

  • Been recommended or scheduled for surgery that has not been complete?
  • Been recommended to have or is anyone contemplating infertility treatment or been treated for infertility?
  • Received or been recommended to have any treatment for alcoholism, alcohol or drug abuse or addiction or mental or nervous conditions?
  • Been cited for operating a moving vehicle under the influence of alcohol or drugs?
  • Received a diagnosis for any serious medical condition such as heart disease, stroke, cancer, diabetes, HIV, AIDS, or any other progressive disabling condition?
  • Been incapacitated or hospitalized due to an accident or illness?

The “good news” is that since we can answer no to all six of those questions, our new premium will be $761.71 per month rather than $842.87 per month.  The mandatory $100 deposit into our HSA remains the same.

A simple 23% increase rather than a 36% increase. 



Earlier this year policy increases of up to 39% in California, Indiana, etc led The House Committee on Energy and Commerce to summon the chiefs of WellPoint, UnitedHealth Group, Humana and Aetna to the Hill to answer questions.  Policy increases by other companies seem to be flying under the radar.


If you missed them, check out the posts by Shadowfax here and here on Assurant Health.

Saturday, February 20, 2010

Not What She Wanted to Hear

Her complaints:  “My back aches.  I can’t find a bra that fits. I have trouble exercising.”

Her Exam:   Moderate size, slightly ptotic breasts. No palpable masses.  No skin changes.

Her Measurements:  33 inch rib cage, 37 inch bust, 24 cm SNN (38C bra)

“Insurance won’t pay for a breast lift.”

Wednesday, December 30, 2009

Appearance Is A Function of the Face

I noticed this article title on MDLinx, then went to the Journal of Plastic and Reconstruction website to read the full article.  The abstract is free to read, the full article requires a subscription.

The study was prompted by the authors noticing third party insurers increasingly deny coverage to patients with post traumatic and congenital facial deformities.  This denial is often cited as due to the deformities not being seen as "functional" problems.  The authors cite the recent facial transplants patients as having demonstrated  that the severely deformed are willing to undergo potentially life-threatening surgery and extended chemotherapy in an attempt in look normal.

The authors also noted that very little research exists which objectively documents appearance as a primary “function” of the face.  To this end, they designed their study to “establish a population-based definition of the functions of the human face, rank importance of the face among various anatomic areas, and determine the risk value the average person places on a normal appearance.” 

Their method involved using  210 voluntary adult subjects in three states aged 18 to 75 years who then completed study questionnaires.  Quota sampling technique was used to select the subjects.  The study questionnaires of demography and bias were done using Gamble Chance of Death Questionnaire and Rosenberg Self-esteem Scale.

Their results:

Subjects ranked appearance as number 5 above expression (number 6), and smell was least important.

Subjects ranked the face as the most important body part to restore after an injury followed by the hand, leg, arm, knee and breast.

Chewing was regarded by most subjects (88%) to be a basic function of the face with over half of subjects (57%) rating appearance as a basic function, and 43% of respondents rating beauty.

68% disagreed with the statement  “Normal facial appearance is not important to be a normal functioning member of society.”

17% of subjects agreed with the statement “Normal facial appearance is irrelevant to being a normal functioning member of American Society”.

A large majority of subjects (72%) determined that surgery to normalize the appearance of facial scars from an accident was functional, as compared to those subjects who thought it was non-functional or not necessary (28%).

Most subjects (79%) reported that surgery to normalize the appearance of facial birth defects was functional, while 21% reported that it was not necessary or non functional; and 72% of the respondents agreed that surgery to normalize the appearance of facial scars from an infection was functional.

The highest ranking of agreement regarding surgery was to normalize the appearance of facial nerve injury; 90% of subjects agreed it was functional while only 10% of subjects agreed it was non-functional.


The authors call this a large sampling, but I don’t feel that 210 subjects is a large sampling.  I would like to see this study repeated with minimally 10 times the number of subjects.  If they want to change insurance policy, I think bigger numbers will be needed. 




Appearance Is A Function of the Face; Plastic and Reconstructive Surgery: POST ACCEPTANCE, 1 December 2009; Borah, Gregory L. MD, FACS; Rankin, Marlene K. PhD; doi:10.1097/PRS.0b013e3181cb613d


Related posts

Face Transplantation – First in the US Done (December 18, 2008)

Cleveland Clinic’s Connie Culp (May 6, 2009)

The Technical and Anatomical Aspects of the World's First Near-Total Human Face and Maxilla Transplant—an Article Review (December 7, 2009)

Thursday, September 18, 2008

Insurance/Healthcare Thoughts

I've been struggling to get a patient's insurance company to give consent for a panniculectomy. I have not been successful. I have appealed the initial reject. It was rejected a second time. There reasoning:

Upon reviewing the submitted information, I have determined that at this time "Excision, excessive skin and subcutaneous tissue; abdomen, infraumbilical panniculectomy" is not a covered benefit under the benefit plan. This determination is based upon the following plan language, found on pages (s) 74 and 125 of the member's Certificate of Coverage or Summary Plan Description:

"Excluded ..... Cosmetic procedures, including cosmetic surgery expenses, supplies, appliances and drugs, except for reconstructive surgery to repair accidental injury

Cosmetic Procedures -- services are considered Cosmetic Procedures when they improve appearance without making an organ or body part work better. The fact that a person may suffer psychological consequences from the impairment does not classify surgery and other procedures done to relieve such consequences as a reconstructive procedure."

I thought I had made it clear, both times, that this proposed panniculectomy was to be done at the request of the patient's dermatologist as the patient's chronic skin rashes/infection in the lower abdominal skin roll could not be treated adequately with conservative methods. How is the treatment of the patient's skin infection/hygiene issues cosmetic?

It seems to me that this patient's insurance company is failing him. This seems to be a recurring theme in recent weeks in the blog world. Check out the recent post and comment section by TBTAM -- In Case You Were Wondering If Health Care is Broken.

Also check out When an MD says Yes and Insurance says NO by Healthcare Today, September 9, 2008

If a credentialed provider determines a specific course of action is reasonable for medical therapy it is amazing that insurance companies can countermand that judgment. Providers may be working as patient advocates, but clearly insurance companies are looking out for their own selfish bottom line. Not a new revelation as most of us would agree.

Monday, August 18, 2008

Inverted Nipple and Insurance

A recent reader of my inverted nipple post has asked for a reference to give to her insurance company.

"i've also been in contact with my insurance company, and they're telling me that if i can come up with an article proving that the severity of my nipple retraction will most likely prevent me from breast feeding, then they will cover my procedure. if you know of any articles that would be helpful. thanks!"

I have had no luck in finding such a reference. All the ones I have found use terms like may or might or can. Does anyone have such a reference?

Nipple inversion can cause functional problems. The condition can be a source of irritation and inflammation, and it may prevent lactation. (reference #1)

Moderate to severe inversion means that the nipple retracts deeply when the areola is compressed, to a level even with or underneath the areola. A nipple with moderate to severe inversion might make latching-on and breastfeeding difficult, but treatment and deep latch techniques can help. --La Leche League

Here are some links regarding techniques that may (there's that word again, no guarantee) help in successful breastfeeding.

Breast Feeding with Flat or Inverted Nipples -- Breastfeeding Essentials Website

Breastfeeding -- Women's Health.Gov

Breastfeeding with Flat or Inverted Nipples --ask DrSears

The websites of plastic surgeons that I visited have a version of this (credit)

Will my insurance coverage pay for my nipple inversion repair surgery?

Nipple inversion repair is a cosmetic procedure and, therefore, not covered by insurance. ........... In rare cases where severe nipple refraction prevents breastfeeding, insurance may pay for all or part of the procedure.

REFERENCES regarding surgical treatment

1. The Inverted Nipple: Its Grading and Surgical Correction; Plastic & Reconstructive Surgery:Volume 104(2)August 1999pp 389-395; Han, Sanghoon M.D.; Hong, Yoon Gi M.D.

2. A Contemporary Correction of Inverted Nipples; Plastic and Reconstructive Surgery:Volume 107(2)February 2001pp 511-513; Scholten, Erik Ph.D.

3. Correction of Inverted Nipples with Twisting and Lockiing Principles; Plastic and Reconstructive Surgery:Volume 118(7)December 2006pp 1526-1531; Kim, Jeong Tae M.D., Ph.D.; Lim, Young Soo M.D.; Oh, Jung Geun M.D., Ph.D.

4. Simple Technique for Inverted Nipple Correction; Morris Ritz, Ram Silfen, David Morgan and Graeme Southwick ; Aesthetic Plastic Surgery Journ, Vol 29, No 1, pp 24-27

5. Surgical Correction of Inverted Nipples Using the Modified Namba or Teimourian Technique; Plastic & Reconstructive Surgery. 113(1):328-336, January 2004; Lee, Kyung Young M.D.; Cho, Byung Chae M.D.

6. Pictures of Correction Surgery (some may consider them graphic)

7. Nipple Inversion Repair; The Metropolitan Institute for Plastic Surgery, Washington DC

Wednesday, August 6, 2008

The Right Thing

I did a precertification for a patient. The precert was for breast reduction surgery. My office had reminded the patient prior to her initial visit that my office was not in her insurance network. We asked her to check her policy to see if she had out-of-network benefits as we didn't want her to get "stuck" with the bill, as it were. My office balance bills, but tries to be up front about costs.

I did the initial visit, reviewed why she felt she needed a breast reduction, did the exam, took measurements and photos, and then after she left sent a letter with documentation (photos, etc) for the precertification.

She received the letter (copied to my office) below which states that she meets her insurance requirements for the surgery. It then clearly states "If Dr Ramona Bates performs the surgery it will not be eligible for reimbursement."

She called to schedule the surgery for early September. I called her back and reminded her that if I did the surgery her insurance would not cover it (not the surgeon, not the surgery center, not the anesthesia, none of it).

"Would you still like me to do your surgery or would you like me to try to find someone in your network?"

"Well, I would really like to have my surgery in September. Do you think you could get me in to see someone soon enough that I could have it done then?"

"I'll try, but I can't guarantee that you might not have to consider a different time for the surgery."

So I called Dr PS1. He is in her network, but can't see her for the initial office visit until September and probably can't get the surgery scheduled until November or December.

Tried Dr PS2. This one, like my office doesn't participate in her insurance network.

Tried Dr PS3 and hit the jackpot for her! They can see her in a week and most likely get her scheduled (since the precert is already done) in early September.

I then called her back and told her the news. "Thank you Dr Bates. I don't know how I can ever really thank you."


Tuesday, February 19, 2008

How Much?!

Recently I was trying to get a patient pre-approved for a bilateral reduction mammoplasty. I sent the usual letter which included her history, her complaints, my physical findings, and my estimate of the amount of breast tissue to be removed. A Polaroid of the the patient's breasts was sent, as required, with the letter. I referenced the Schnur sliding scale (a scale that uses the patient's height and weight to determine the minimum tissue needed for removal to give relief of their physical complaints). I was certain she would be approved as I felt she met all the requirements, but I like to be certain.

About six weeks after the letter was sent and several phone calls, I received (and the patient got the same copy) a letter denying the surgery as she failed to meet the minimal tissue removal guidelines. I need to remove how much tissue?!

I re-read the letter. They too referenced the Schnur sliding scale (SSS). I called the physician reviewer, feeling like they had just misunderstood. Their letter stated "tissue removed per breast". I understood the SSS to be "total tissue removed".

I actually had a very pleasant conversation / exchange with Dr Insurance. He listened and let my fax him my copy of the original article. He then called me back and informed me that I had misread the article. I was confused (granted it had been years since I had re-read it, but I "knew" what it said) but looked again as we talked. Damn, he was right. As he pointed out, the original article measured the amount of tissue removed from the RIGHT breast only and not both added together. So the scale is per breast not total tissue removed.

Well, I have been looking back over all the information I have and have finally figured out part of the source of my confusion (other than simply wanting it to be so, as it makes it easier to accommodate these women). I scanned in a copy of the BCBS Manuel page I printed out back in July 2001. Note the heading says "Total Breast Tissue to Be Removed". Today when I type in the web address at the bottom of the same page, this is what you will see "Tissue per Breast". Same web address, but they corrected it some time between 2001 and now.
Why does it matter? Well for a patient who weights 225 lb and is 5'8" tall (BSA 2.21), approximately 750 gms of tissue have to be removed from each breast, not 300 gm from one and 45o gm from the other for a total of 750 gm. That's approximately 1.5 lb of breast tissue per side, and for most women that size 3 bra cup sizes.

Another example, 5'1" tall and weights 155 lb. This woman would have a BSA of 1.74 and would have to have 400 gms of breast tissue per side removed. That's at least 2 cup bra sizes for her.

That seems fair. It's hard to promise them (the patients) that you can remove that amount sometimes. It can also be difficult to estimate the amount to be removed just by exam. There was a recent article (see reference #2) that has a formula for the estimation. I may try it and see if it is any better than my "eye". The formula is 35 X sternal notch to nipple distance in cm + 60 X nipple to inframammary crease distance in cm - 1240.

The woman that prompted all this, I estimated about 200-300 gm less per side than required. I'm not willing to make her a "B" cup just to meet the requirements (see my reasons here). And over-estimating the amount and then not meeting it can get a "not covered" and no payment after the fact. Thankfully, Dr Insurance approved her for me. He felt that I was doing her for the "correct" reasons. I appreciate the discussion we had.

Reduction Mammaplasty: Cosmetic or reconstructive Procedure?; Annals of Plastic Surgery, Vol 27, No 3, Sept 1991, pp232-237

A Formula Determining Resection Weights for Reduction Mammaplasty; Plastic & Reconstructive Surgery. 121(2):397-400, February 2008; Descamps, Marjanne J. L. M.R.C.S.; Landau, Alex G. M.B.; Lazarus, Dirk F.C.S.; Hudson, Don A. F.R.C.S., F.C.S., M.Med.