Progress for Lipedema Surgery Coverage
We have made significant progress during the past few months. Over 60 more women have been fully covered by various insurers, bringing our total to almost 120. We have successfully convinced the second-largest Blue Cross Blue Shield plan in the country, Health Care Service Corp (BCBS of TX, IL, MT, OK, and NM), BCBS of Michigan, and Medical Mutual of Ohio to issue coverage policies for lipedema surgery. Other BCBS plans in North Carolina, Arizona, and New Jersey have covered patients at least once and are likely to issue coverage policies soon. Additionally, Medicare has issued a proposed coverage policy.
Great Challenges Remain
However, there are still significant and increasing challenges in getting surgery covered that we had hoped would have been resolved by now. One challenge is in California, where both BCBS plans cover but insist on using less qualified network providers. An out-of-network provider’s failure to go in-network as promised has left several women in limbo. We also have issues with less qualified network providers in Ohio and Washington State as well. Additionally, several insurers are refusing to pay out-of-network providers fairly, including BCBS of Texas and Illinois.
Questionable Billing Practices May Harm Lipedema Coverage
We have noticed a trend that could jeopardize future lipedema coverage for patients with PPO insurance. It seems that some out-of-network surgeons are getting broad prior authorizations that require a patient to pay their surgery fees in full upfront. The surgeon then bills high amounts to the insurance company after surgery, hoping that the reduced out-of-network reimbursement will still cover their costs and let them reimburse the patient (sometimes with much profit to the surgeon). This approach has succeeded a few times, which has caused some surgeons to keep trying it. Unfortunately, this practice puts all of the risk of reimbursement on the patient. Also, this seems to have caused some surgeons to be flagged for fraud or abuse by insurance companies which may lead to future claims being denied, once again at the risk of the patient. This could also cause patients to be implicated in this questionable practice. Moreover, when insurers see that surgeons are using questionable billing techniques to get payment, it makes all lipedema surgery requests suspect and undermines the successful process that we have created to get fair coverage for lipedema surgery. As always, be wary of surgeons who want you to pay upfront, regardless of their promises.
Increasing Difficulty for Network Exceptions and Single Case Agreements
We are finding that it is increasingly difficult to get insurers to approve network exceptions and enter into single case agreements. Aetna has even recently balked at these agreements and is often proposing less-experienced network surgeons. We currently list only two network surgeons on our website, and it is clear we need to find more experienced surgeons in network. Dr. Karol Gutowski, who is insurance friendly but not interested in going in-network, has offered to train any board-certified plastic surgeons interested in treating lipedema.
We are Still Committed to Getting our Members Covered
Although we are committed to getting our Coverliepdema.com Members fully covered by insurance, we have come to recognize that more of our time is required in the appeal, network and payment processes. We had hoped that having more women getting covered through Coverlipedema.com would change policy quickly, and to some extent, it has, but the issues that we encounter are complicated and can be better resolved if we are more involved in each person’s case. Because of this, we are changing our membership benefits and pricing structure for new members, as well as adding optional upgrades for existing members, so we can get people covered quicker and easier.
New Member Pricing Structure as of April 28, 2021
Coverage Process Membership is still $500.
Appeal Process Membership with Personal Advocacy is now $875. Instead of Members submitting appeals, Coverlipedema.com will take a more active role in submission and have proactive discussions with insurers, regulators, and review agencies, as needed, to ensure fair coverage. This includes helping you avoid “independent” review organizations that always deny lipedema surgery by using unqualified reviewers.
Network Process Membership with Personal Advocacy is now $1,000. This is a greatly expanded process representing several extra hours of additional service. Coverlipedema.com will prepare and submit network exceptions and engage insurers at a higher level for members than previously provided for the original Network and Payment Processes. We will also assist with the negotiations between insurers and surgeons to reach agreements, including involving employers or regulators when needed to move the process along quicker.
We feel that this new pricing structure, including focused personal advocacy will allow us to devote more time to Members who require assistance to get their surgeries covered. Unfortunately, that means just about everyone given the current state of coverage. We will continue to provide discounted memberships to low-income members who qualify.
Existing Member Upgrade Pricing as of April 28, 2021
We value our integrity and want you to know our word is our bond. So, we will honor any prices that we have previously quoted to our Members. Members who joined Coverlipedema.com before April 28, will still be able to upgrade based on their original Coverage Process, Appeal Process and Payment Process membership terms. However, those upgrades will not include the expanded benefits of Personal Advocacy. Upgrades that include those benefits will be available and will have a discount to be determined. We’ll be glad to discuss upgrade pricing individually when it becomes an option for our Members.
Our Goal for Lipedema Coverage
We still believe that our results, with an average of $50,000 in surgery fees covered per Member, make membership necessary and worthwhile for anyone seeking to cover their lipedema surgery. We guarantee that we will continue to help you even if you don’t get covered or have no choice but to pay upfront because of network issues. Our goal remains to make lipedema surgery like any other surgery so that one day patients will have easy access to qualified network surgeons in several states.