My Surgeon Billed my Insurance and Collected Even After I Had Already Paid in Full out of Pocket. Is This Right?

I had TT & BA in January. The TT was denied by Tricare previously. By Jan, I had BCBS, but assumed it still would not be covered, so I just paid out of pocket. I paid $9600 total, of which $4500 was for the TT. Afterward, they billed BCBS $24,700 for "diastasis of muscle" which was covered, & my share would have only been $992. I've had many F/U appts & a revision at no cost, but still feel this was dishonest. I really like my PS & I'm happy w/ the results. Am I right to ask for a refund?

Doctor Answers 4

Insurance Billing for a Cosmetic Procedure

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This is not as uncommon as you may suspect.  If you do the surgery as a cosmetic patient and pay up front without the understanding made in advance that the physician and facility may bill for certain aspects of the procedure deemed "cover services" by your insurance company then it would certainly seem to be unethical.  The fact that a physician will bill such a high fee and get paid so little is typical for insurance company reimbursements, and is one of the reasons most plastic surgeons don't accept insurance for these procedures since the payment is minimal and not reflective of the extent of the surgery performed.  It may be that the initial pricing for your procedure was reduced with the expectation by the physician that in billing the insurance company they would recoup a modest amount thereby not charging you as much: in which case you wouldn't be due a refund for the covered part of the procedure had you agreed to this at the onset. You need to let your conscious dictate what to do but asking your insurance company will not give you any answers but only misinformation. In the end I think you just need to be aware that this possibility exists when you have plastic surgery and you should ask more questions. You may have received a financial benefit without you knowing  because you probably have a deductible on your plan that the physician's office may have informed the insurance company that you met it, when you paid for the surgery, in order for them to receive what they did from BC. That means the next time you need medical or surgical services this year most if not all of your deductibles may have been met so you won't have as much out of pocket expense.

Orange County Plastic Surgeon
4.9 out of 5 stars 65 reviews

Insurance billing after self-pay tummy tuck

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Thank you for asking about insurance after self-pay tummy tuck and breast augmentation.  Every policy and insurer has different criteria for reimbursement. In this case, Tricare had rejected but BCBS approved the diastasis repair under your new policy.

  1. A tummy tuck is more than diastasis repair.
  2. Insurance paid only for the diastasis repair.
  3. You are due a refund of what you paid for the diastasis repair less its copays/deductibles, if your surgeon participates in BC/BS,  If not, you get a refund for what you paid for the diastasis, up to $992.
  4. Call the surgeon and your insurer to sort this out.

Billing Ethics

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If these are the facts concerning the financial aspects of your operation, it is my opinion that this is very unethical.  You can inform your insurance carrier of the situation and they will investigate further.  You may also consider letting the state Medical Board know of this sequence of events.

Bruce Carter, MD (retired)
Salem Plastic Surgeon

Cosmetic surgery Billing

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If the procedures of Tummy Tuck and  Breast Augmentation is done for cosmetic reason, then it is not covered by any insurance. Double billing is illegal. and if you ask and receive a refund then you are also part of the fraud.

Samir Shureih, MD
Baltimore Plastic Surgeon

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.