What is the average out of pocket expense for a breast reduction if insurance has approved paying 80%?

Question

What is average out of pocket expense for a breast reduction, if insurance has approved paying 80% ? Blue Shield is says my out of pocket is $6500.

Keith M. Blechman, MD · Answer

The out of pocket cost for an in-network, insurance-based breast reduction is related to what insurance carriers refer to as the allowed amount. The allowed amount is a number the insurance company decides for each code that is billed by the doctor (there is a code to describe each type of medical procedure, including a specific code for a breast reduction). How the allowed amount for each code is derived is always a mystery but is based on your individual plan and the contract the insurance company has with your doctor. The allowed amount is what the doctor will be owed. If your insurance will pay 80% then you will owe 20% of the allowed amount to the doctor, but usually only up to your out of pocket expense. So, if the allowed amount is $1,000 then you're insurance company will pay $800 and you will owe $200 (if you haven't yet spent any out of pocket expenses this year). However, if the allowed amount were to be $40,000 then you would only owe $6,500 because that's your out of pocket maximum (even though it's less than $8,000, which is 20% of $40,000). However, if you have a deductible then you may still owe that outside of your out of pocket maximum. It's best to call your insurance company and ask.

Best of luck,Keith M. Blechman, MDNew York, NY

Best of luck,Keith M. Blechman, MDNew York, NY

Jaime S. Schwartz, MD, FACS · Answer

I appreciate your question.

Cost varies by geographic location, surgeon expertise, OR time, anesthesia, length of procedure etc.  I would recommend that you go to The American Society of Plastic Surgery website and look for a list of board certified plastic surgeons in your area.  You can call their offices in advance and ask for quotes prior to scheduling consultations.

The best way to assess and give true advice would be an in-person exam.

Please see a board-certified plastic surgeon that specializes in aesthetic and restorative plastic surgery.

Best of luck!

Dr. Schwartz

Board Certified Plastic Surgeon

Director-Beverly Hills Breast and Body Institute

#RealSelf100Surgeon

#RealSelfCORESurgeon

Fred Suess, MD (retired) · Answer

It is difficult to evaluate because the question of what your deductible is, if you have met it, if you are in network or out of network for the facility. It is best to have a consultation and let the doctors office evaluate (by consulting) with your insurance company.The $6,500 quoted from your insurance company seems high to me.

Vincent D. Lepore, MD (retired) · Answer

This is a very good question and I believe Dr. Blechman has give a very good answer to the cost that one might experience when having the surgery performed at an "in-network" hospital.  In all likelihood the largest expense, by far, is the cost of the hospital operating room and recovery facilities.  In our practice, we have our own free standing out patient surgical center, which routinely charges far less that the average in-network hospital fees.  In most cases, we have been able to save patients a significant amount of cost by having the procedure performed in our surgical center, even though it may be "out-of-network" on some insurance plans.  Check with your surgeon to see if such an option is available to you.  Best wishes, Dr. Lepore.

Ronald V. DeMars, MD (Retired) · Answer

There is no answer to this question. The only number that matters is your specific instance. See a surgeon to find out if you are authorized by insurance, then find out what your insurance allows and what it pays.

What is the average out of pocket expense for a breast reduction if insurance has approved paying 80%?

Answers (5)

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