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

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.

Doctor Answers 17

A breast reduction include a lift and areolar reduction

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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 the surgery. The key is to not go to an inexperienced doctor who takes insurance and believe that this doctor will give you the same result as an experienced surgeon.

It all depends on the insurance.

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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 that even if the surgery is "covered" by insurance, the insurance company pays the surgeon considerably less than the market rate for the surgery. Good luck with your procedure.

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

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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 or she can set his or her own criteria for accepting insurance.  And that's part of the problem.  Often the procedure may be "covered" -  but only to the extent that you can find a surgeon you like who will accept what the insurance company say says is the appropriate payment as FULL payment.  And that's where the confusion is.

So - you need to speak with your PS and find out his or her status in the insurance company.  And then you'll have to make a decision concerning what you want to do.  You may have to pay additional out-of-pocket expenses in order to get the surgery done by the surgeon you want.  That, perhaps unfortunately, is often just the way it is now...sorry about that.

But I hope that this has helped, and good luck,

Dr. E

Get clarification from Doctor

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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.

There may be insurance carrier issues that I am not aware of. If your surgeon cannot clarify issues for you, seek other opinions from experienced board-certified plastic surgeons.

Sutton Graham II, MD
Greenville Plastic Surgeon

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

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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 (retired)
Manhattan Plastic Surgeon

Breast reduction is a fuzzy area...

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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 your surgeon is charging extra if he is using a traditional skin reduction pattern reduction since this incorporates the lift, however one can be quite picky and break down the traditional reduction into its pieces (i.e. removal of weight, shaping of skin, lifting of nipple, reducing size of nipple) and charge a la carte.

I suspect it is in much part due to what is being allowed as a fee by your insurance. If your surgeon is not part of the insurance plan, then he may be free to charge anything he wishes without regard to the insurance reimbursement. This would be quite normal as the insurance payment usually is far below the going rate in private practices outside of insurance plans.

If he is in the plan, he might justify he charges by saying the insurance will pay for removal of the weight without regard to the aesthetics, say by liposuction, and that you will need to pay to have him shape it to look the way you want, and that is something the insurance may not pay for.

The insurance company might say it is all-inclusive and not have to worry about what is included because they are paying a self-determine fee anyways. It can be a fuzzy area.

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

Breast Reduction Additional Fees

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Please ask your surgeon about this. These things tend to be covered by the breast reduction, but they may be able to explain why this isn't the case here.

Combination of Noncosmetic and Cosmetic Procedures

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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
4.5 out of 5 stars 56 reviews

Breast Reduction and Charges?

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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.

Insurance covers procedure but surgeon asks for payment

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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.

Otto Joseph Placik, MD
Chicago Plastic Surgeon
4.9 out of 5 stars 86 reviews

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.