(For those of you who missed our Summer Update last month and for those of you who are not on our mailing list, we are posting it here in our blog.)
The past few months have been very active for lipedema insurance coverage. We have now helped over one hundred sixty women get millions of dollars of coverage for their surgeries. We are continuing to face the challenges of lipedema surgeons who claim to be insurance-friendly, but are not, and insurance companies who claim to cover lipedema fairly, but don’t actually. We are still fully confident that we can help women get coverage without paying the full amount out-of-pocket.
United Health Care Settles Lawsuit
Some surgeons are touting the news of the settlement of a coverage lawsuit by UnitedHealthcare (UHC) and its promise of a coverage policy as a major development. We are not so excited. It’s our opinion that this settlement will only benefit the law firms that filed the action and the unscrupulous surgeons who will use the news of it to convince their patients to pay in advance, hoping for a reasonable reimbursement that will never happen. It’s easy for an insurance company to agree to a coverage policy that does not require fair payment or an adequate network of surgeons. Until insurance companies cover lipedema surgery with highly qualified surgeons who are paid fairly, then women with lipedema will continue to be forced to pay for their surgeries with little hope of fair reimbursement.
Cigna Issues Coverage Policy
Cigna also issued a coverage policy for lipedema on 6/6/21. They are covering the legs and arms along with excisions, but not the trunk or abdomen. We can easily appeal and win those areas as they are not excluded, just not mentioned.
Implications for CIGNA and UHC Members
Anyone who has Cigna or UHC should think about applying for coverage now and we can address the network issues during the Coverlipedema.com process. These plans will be forced to deal with the fact that there are a limited number of surgeons. However, we continue to have issues in some states like California and Ohio, if you live there or go there for surgery. There are less-experienced, primarily lymphedema surgeons, such as Dr. Ketan Patel of USC and Dr. Roman Skoracki, who claim they regularly treat lipedema, who make it difficult to get out-of-network exceptions.
Implications for Everyone Else: Coverage Policies Don’t Mean Much for Fair Out-of-Network Coverage
We have seen this with Anthem Blue Cross Blue Shield in California covering lipedema, but limiting coverage to network surgeons. Even, Aetna, which has been one of the best insurers, is recommending network surgeons who have questionable qualifications. We believe there may be ulterior motives underlying the suggestion of unqualified surgeons to discourage women from seeking insurance coverage. This, unfortunately, perpetuates a system where women must pay cash to surgeons who promise to “help” but don’t have the experience, connections, or desire to ensure patients are not forced pay out-of-pocket for medically necessary surgery. There are surgeons, who we no longer work with, who talk about single case agreements like they are easy to get, yet privately state women should be happy to get even a small reimbursement. Always question any request to pay cash for surgery or an approval for only out-of-network coverage that doesn’t allow for a single case agreement.
What This News Means for Lipedema Coverage
The silver lining of the UHC and Cigna policy changes is that if you have another insurance plan that has not covered lipedema before or has a policy stating that the surgery is unproven (BCBS of MN, FL, OR, AL, AR), it’s going to be even harder for them to beat you on external appeal. So, now is the time to get your surgery covered. We will have network issues with these plans, too, but we can deal with them.
Eventually, we expect that insurers will treat lipedema like some weight loss surgery or fertility treatments. Insurers will cap the amount of payment for lipedema surgery and self-funded employers will also limit spending or even exclude any lipedema treatment from their plan. This creates some urgency to get coverage as soon as possible before these restrictions are enacted.
We Have Good News, Too.
A few new insurers are covering lipedema and entering into single case agreements for the first time, like Blue Cross Blue Shield of New Jersey, New Mexico, and North Carolina. Smaller plans and unions continue to be relatively easy to deal with. We have also helped several members quickly transition to network surgeons like Dr. Omar Beidas in Orlando due to continued problems with BCBS of Texas and Blue Shield of California who we keep pressing on their lack of network surgeons.
What’s Coming Up
The next months for us will involve pushing every insurer to provide access to qualified surgeons while we search for more qualified surgeons. We do this with every member, and we work at higher policy levels with state and federal regulators. This will take some time, as one surgeon told us that he doesn’t like to do lipedema cases because cosmetic cases are easier and pay better. However, we believe there are surgeons who would go in-network and can be paid reasonably for doing satisfying work that helps women regain their health and wellness. We enjoy the work we do with women with lipedema. It’s hard and we have worked less for more compensation solving other problems, but we believe it’s important work that must be done.
What Should You Do
If you have had your surgeries covered by Coverlipedema.com, let everyone know how women can get their surgeries covered with the lowest out-of-pocket cost possible.
If you are a Coverlipedema.com member, you should continuing working on your coverage and appeal packages. Now is not the time to procrastinate.
If you are considering joining, now is the time to start working with us to get your surgeries covered. There are a limited number of insurance-friendly surgeons, so they are often booked up for several months in advance. Since even with the better insurers, it can take a few months to get everything together, now is a good time to plan on getting your surgeries done in 2022 so you can leverage your coinsurance payments and deductibles. Make an appointment on our website to speak with us.
For Your Best Opportunity for Fair Coverage Always Remember:
· Choose competent network surgeons.
· If you don’t have a competent network surgeon, choose only out-of-network surgeons who are board-certified plastic surgeons and who will enter into single case agreements.
· Never, ever choose a surgeon who requires that you pay in-full upfront.
If you have questions about lipedema coverage, please reach out to us. We are here to help you on your lipedema journey to health and wellness.