My insurance has approved abdominoplasty , panniculectomy and and mastodopexy - why do surgeons not accept insurance?

The reason most plastic surgeons do not accept insurance is because reimbursement can be as low as 25% of billed price. If a procedure is covered, I have the patient pay upfront and we submit to the insurance company approving the procedure. The insurance company then pays you the amount they cover.Hope this helps.

No insurance will cover abdominoplasty and mastopexy which are both cosmetic surgeries. The approval needs to be initiated by a doctor not the patient.
Panniculectomy needs to have caused serious medical issues with documentation of the events and present certain criteria to be approved.

Most plastic surgeons do not accept insurance because the reimbursement amount is too small and usually delayed. Some insurance companies refuse to pay at all.

Best Wishes,

Gary Horndeski, M.D.

Hello, thank you for your question. Reason being that a plastic surgeon will not accept the fact that the insurance company will pay for these things is because most times they end up not paying or paying next to nothing. The payments that are received from insurance does not even cover the cost of supplies most times. Best of luck !

Medical insurance companies all do what they can to not pay. And in the area of surgeries like these, they are not shy to literally not pay, even when you are 'approved'. You should look into going to a plastic surgery department associated with a medical school that has postgraduate plastic surgery training. They will take your insurance.

A tummy tuck is almost never covered by insurance although a breast reduction is often covered. There seems to be some confusing or uncertain information about your individual case. I would recommend you go to one of the universities in Chicago. They are more likely to accept your insurance and have the resources to sort out what sounds to be a confusing situation. That may be why the plastic surgeon you consulted doesn’t want to do your case.

You can find plastic surgeons who do take insurance, especially in University Hospital settings. They may choose to do the breast reduction separately from the panniculectomy. Just for your knowledge, your surgery would be panniculectomy and breast reduction. A breast lift by itself is not covered, but is part of the reduction. Most abdominoplasties are considered cosmetic, too. Perhaps when you are looking for a surgeon, use the correct terminology. No insurance covers 1000% and most BCBS policies cover 70-80% of the fees. You would need to pay the rest upfront. Also, bring the letter from the insurance company stating that they will provide coverage for the procedure. Word of mouth is not sufficient.

Insurance companies are notorious for either not paying at all or paying very little. You may want to contact your insurance company for surgeons that take your insurance for these procedures. I'm not sure how much success you'll have. Be sure to do your research to ensure your surgeon is board certified and experienced.

Sorry to hear about your experiences so far. I do accept insurance and do these procedures all of the time. But, just to clarify... and just so you know.... I'm not sure how your PCP got you coverage for these procedures if he/she doesn't perform them. I've never hear of that. If you or they called the insurance company and asked of these procedures are covered, the stock answer the insurance companies all give is YES, These are covered procedures if "Medically Necessary"! Then when we actually submit the pre-authorization informationto the insurance company, they decline coverage. Here is what I have experienced in dealing with insurance companies, (including BC/BS which is the only insurance I accept) They never cover a Tummy tuck. They do cover a panniculectomy. There is a major difference in these 2 procedures. A panniculectomy would be like taking a pair of scissors and cutting off the overhanging roll of skin and sewing it back together. That takes about 1-1.5 hours. And, the only reason they will pay for a panniculectomy is if you have infections where your skin lays on skin. This is what makes it medically necessary. A tummy tuck is much more involved, including undermining your skin up to your rib cage, reconfiguring your belly button, repairing your muscles, stretching your skin as tight as possible, removing the excess skin and sewing things back together. This is usually about a 3 hour surgery, and is way more than is necessary to treat the folds of skin causing the infections. That is why insurance will not pay for a tummy tuck.
Yes, they will pay for hernia repair. And, yes they will pay for Breast Reduction surgery... if you meet the requirements of Neck pain, back pain, shoulder pain or infections where your skin lays on skin. But, they will only pay for breast reduction if the amount of breast tissue removed meets their requirements. What this weight requirement is is based on your height and weight or body surface area. If at least this amount of breast tissue weight is not removed, insurance will not pay for the surgery, including Operating room fee, anesthesia fee or surgeons fee, leaving you stuck with all three bills.

This is a very interesting question. If you review the approval, you think you have from your PPO insurance it states in most insensitive and not all billing and approval will be based after the procedures form therefore there is no guarantee of coverage. With that in mind plus the amount of reimbursement of the insurance company is far below the standard fee, the majority of board certified plastic surgeons charge for those procedures. if your surgeon in the hospital or outpatient center, you’re going to use accept insurance coverage with a upfront payment of cosmetic portion of the procedure then you could probably find somebody in your area. If not, you might have to travel to another city in the United States. Even with this Insurance question approval the out-of-pocket fee would be easily $10,000-$15,000 in the combination. Best to virtual consult with for further explanation. Good luck.