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Why is the Doctor Charging Extra if Breast Reduction is Covered?

asked 3 years ago by mimijess in miami,fl
Latest answer by Kris M. Reddy, MD, FACS
Question viewed 1,644 times

My breast reduction was approved by Tricare. Doctor is charging me $3,500 for a breast lift and nipple reduction. Aren't breast lift and nipple reduction part of breast reduction? Should I pay extra? Should it be included? What should I do? Thank you.

16 answers to Why is the Doctor Charging Extra if Breast Reduction is Covered?

A breast reduction include a lift and areolar reduction

Reducing the areola and lifting the breast are part of a breast reduction. You should discuss the charges with your surgeon and ask for clarification. Please understand that the amount the insurance will pay the doctor is a tiny fraction of the bill so don't be mislead by believing that the doctor is being paid in full. Many plastic surgeons actually don't take any insurance anymore and you would be asked to pay in full preop and try to get some reimbursement from your insurance after... more

Richard P. Rand, MD, FACS
Seattle Plastic Surgeon

Get clarification from Doctor

Mimijess: In general, insurance or self-pay breast reduction includes removal of excess skin, fat and breast tissue. The areola (not the actual nipple) is lifted and repositioned as part of the procedure. Additional liposuction of the lateral chest is not included, but often helpful. Additional reduction of overly prominent nipples would not be included. As other surgeon's posts have mentioned, insurance reimbursement is much less than typical charges for the breast reduction procedure... more

Sutton Graham II, MD
Greenville Plastic Surgeon

It all depends on the insurance.

It all really depends on your insurance and the doctor. A breast reduction involves moving the nipple and lifting the breast by definition. If your surgeon is "in-network" for your insurance plan, then he is obligated to take whatever the insurance pays. However, if he is "out-of-network," then whatever the insurance covers just supplements his or her fee and your are responsible for the rest. It is entirely up to you if you want to go to an "in-network" surgeon or not. Keep in mind... more

David Shafer, MD
New York Plastic Surgeon

Insurance may only pay a part of your surgeon's fee.

Hi! If your surgeon is out of network, then he is free to charge you his usual fee. If your surgeon is in your plan, however, then he cannot charge you extra, because, as you say, lift and nipple reduction are integral parts of breast reduction and cannot be billed for separately.

George J. Beraka, MD
Manhattan Plastic Surgeon

Breast reduction is a fuzzy area...

There are a multitude of procedures referred to as breast reduction, including simple liposuction. Some involve long scars and some short. From an insurance point of view, the only real concern is relief of the weight of the breast producing neck, back, or shoulder strain. This can potentially be accomplished with just liposuction without regard to shape, form, or aesthetics of the breast. Breast lifts generally address the shape and form of the aesthetics of the breast. I do not know why... more

Robin T.W. Yuan, MD
Beverly Hills Plastic Surgeon

Combination of Noncosmetic and Cosmetic Procedures

Depending on your plan breast lift and nipple reduction may be deemed as cosmetic surgery procedures. Breast Lift and Nipple reduction are distinct procedures from breast reduction.

Kris M. Reddy, MD, FACS
West Palm Beach Plastic Surgeon

Breast Reduction - Why is the Doctor Charging Extra if Breast Reduction is Covered?

Good question - and the answer may or may not be straight-forward. Fist, in GENERAL, if you're using an in-network surgeon and the proposed procedure has been approved by the insurance company, then there should not be additional charges for you. A breast lift and nipple reduction (I'm assuming you mean a reduction of the areola) are typically part of a standard breast reduction. If, however, you are using a surgeon who does not participate in your insurance then he... more

Alan Engler, MD
New York Plastic Surgeon

Breast Reduction and Charges?

It will be most accurate if you ask your plastic surgeon's office about the specifics of billing; online consultants can only speculate. Best wishes with your upcoming surgery.

Tom J. Pousti, MD
San Diego Plastic Surgeon

Insurance covers procedure but surgeon asks for payment

If your surgeon does not participate with Tricare, he may not recieve payment (you may get the check) therefore it is reasoanble for him/her to ask for payment in full pre-operatively. If he/she does participate, then itis likely that they will have to accept Tricare payments minus the obligated co-pay. see video

Otto Joseph Placik, MD
Chicago Plastic Surgeon

Breast reduction fees

Before your surgery carefully review all the expected fees for your breast reduction surgery. This can be a very confusing area when dealing with insurance. Every insurance policy is different and each has different requirements for the surgeon and patient as well. Make sure that you understand where each portion of the fee will cover.

B. Pat Pazmino, MD
Miami Plastic Surgeon

Ask your surgeon about fees

Your surgeon may be including surgery that is not covered in the procedure for which the insurer is paying. Get this cleared up before your surgery date so there are no surprises. Best Regards.

John P. Di Saia, MD
Orange Plastic Surgeon

Breast reduction and insurance

The insurance company may only be paying for a poriton of the breast reduction surgery. You should talk with your doctor's office and get clarification of the fees.

Steven Wallach, MD
Manhattan Plastic Surgeon

Breast Reduction and Insurance coverage

A breast reduction is one of the most labor intensive procedures that plastic surgeons perform, and it takes a significant amount of time (both in the operating room and for aftercare visits) to do correctly. Insurance reimbursement is not consistent with the amount of work involved, and with some carriers, it is actually insulting. Because of this, it is difficult to find a senior plastic surgeon who will accept insurance payment for a breast reduction. As was suggested above, you need... more

Michael A. Bogdan, MD
Dallas Plastic Surgeon

Breast reduction includes lift and areola reduction

Breast reduction includes a breast lift and reducing the size of the areola NOT the nipple. If your nipples are also being reduced, then that can be billed separately. However, if you have an HMO and your doctor is on your plan, then your doctor has to accept payment from the insurance company for a breast reduction (not nipple reduction). If you are on a PPO and you see a surgeon not on your network, then they can charge you any fee they wish. You do need to know that many insurance... more

Sirish Maddali, MD
Portland Plastic Surgeon

Discuss the fees with the doctor so you are fully aware

Hello mimijess, Having your breast reduction "approved" does not mean the insurance company will pay the doctor. We have been in a situation where a major carrier "approved" a breast reduction. The patient loved the results, had complete improvement in symptoms and the carrier denied payment. Why? Arbitrarily they said we "did not remove enough" to cover it, even though the procedure was "approved" with photos ahead of time, all symptoms went away and... more

Francisco Canales, MD
Santa Rosa Plastic Surgeon

These are part of the procedure

Reducing the diameter of the areola and lifting the breast is all part of the procedure. There should be no extra fees for adding these. However sometimes, there would be an extra fee for the removal of tissue near the arm pit.