An Active Summer
We are validated by the continuing success of our Coverage, Network, and Appeal Processes combined with insurance-friendly board-certified plastic surgeons to get full and fair coverage of lipedema surgery by insurance. We have helped dozens of women get covered this past summer and are now up to over 200 women covered with 10 million dollars in coverage! We also have continued our best efforts to expand lipedema surgery coverage in the United States by encouraging insurance companies to expand their network of qualified surgeons. This past summer has included the issuance of new coverage policies and some new challenges for out-of-network coverage.
Now is a good time to work on your submission so you can get all your surgeries done in the 2022 plan year. We believe there is some urgency because we expect that employer-based plans might start to cap or limit lipedema surgery in the future, as they have done with obesity surgery and fertility treatments in the past.
New Coverage Policies
Cigna, CareFirst, and United Healthcare have issued coverage policies this summer. The Cigna and CareFirst policies do not cover the trunk, but we have won trunk coverage easily on appeal, and we have prior approvals by these plans that did cover the trunk. There could be some network issues with traveling to see out-of-network surgeons that we have to handle on a case-by-case basis. As for United Healthcare, we covered the new policy in some detail on our insurance page on Coverlipedema.com. We have not submitted a coverage request under its new policy, which became effective October 1st. However, the policy creates several challenges for coverage, including a six-month requirement for conservative measures. As we have found with other insurers that issue policies, we expect these companies to do a poor job training their clinical teams about lipedema. Just because a policy exists does not mean that coverage will be easy or likely.
Existing Coverage Policies
Even when insurance companies have coverage policies, they still inconsistently deny women for coverage. Even Aetna and Anthem have recently denied on the basis that liposuction is cosmetic and not medically necessary. We also expect to appeal for excisions and surgery on the trunk, including panniculectomies. However, there have been a few cases where everything, including excisions and a panniculectomy, has been approved without appeal. We always add the latest information about these approvals to strengthen member coverage requests.
The Continuing Importance of an Effective Coverage Request
Regardless of coverage policies, it’s essential to have an effective coverage request, and we guide you through the steps to create one with our Coverage Process. You need to include many elements to argue successfully that your lipedema surgery is medically necessary. Minor errors in wording by a doctor, including mistakes in the surgical plan, can cost you time and money. We review your request like an insurer would and then reach out to the insurer at the highest level to ensure that your package is properly reviewed and processed.
While you might get lucky doing this by yourself or with a surgeon, almost all of our members get covered for ALL their surgery costs, and we guarantee to keep working with you until you are covered. A surgeon’s office doesn’t have the experience, connections, data, or the desire and time to advocate for you. We only work with surgeons who are board-certified in plastic surgery and who have a history of being insurance friendly. They don’t usually advertise or dominate social media because they are busy enough or are employed by a hospital. They don’t pressure patients to pay cash upfront or tell them inaccurate information about the process. They are healers, not medical entrepreneurs looking to profit from the latest surgical trend.
If you are denied in full or in part, we can overturn most cases with our effective Appeal Process. This summer, we overturned Blue Cross Blue Shield of Oregon for the fourth time, and BCBS of North Carolina and BCBS of Alabama each for two members. We also are winning coverage of excisions and tummy tucks (panniculectomy) for lipedema directly and on appeal.
Out-of-Network Providers can be Challenging
Once you are covered, the process doesn’t end unless you are willing to wait for a network provider. In the past few months, Aetna has been reasonable with out-of-network providers, but they have not approved flying cross country for surgery. Anthem is still very difficult, as is Cigna, but United Healthcare and a few other state-based Blue Cross Blue Shield plans are being more reasonable. In the past few months, we have successfully gained approval for out-of-network surgeries for our members with Chicago based board-certified plastic surgeons, including:
- $90,000 of surgeries for a member who lives in North Carolina with BCBS of Texas;
- $80,000 of surgeries for a member who lives in Maryland with CareFirst;
- $120,000 of surgeries for a member who lives in Oklahoma with United Healthcare;
- $100,000 of surgeries for a member who lives Tennessee with United Healthcare.
We can get you to the surgeon of your choice most of the time. From start to finish, the process usually takes between three and six months. Depending on your state and insurer, we will let you know if having an alternate plan makes sense. Often, we can help approved members pivot to a network surgeon quickly when the out-of-network options are impractical.
The Need for More Board-Certified Plastic Surgeons
We are working hard to find more board-certified plastic surgeons who will treat lipedema, and we have a few new ones we are talking with now in Pennsylvania and Tennessee. We actively seek network surgeons in Ohio, Texas, Michigan, and California, where it can be difficult to see an out-of-network surgeon. We are always happy to work with members who want to find a willing surgeon close to them.
Membership Fee Updates
As a reminder, our membership fee starts at $500. If you are working with a non-network surgeon, we have lowered our Network Process fee. The fee is either $500 or $1,000 depending on whether the insurer disputes the network exception request or the payment amount.
To offset the costs of getting covered, we provide guidance on how to submit claims for your consultations, compression garments, MLD, and even travel due to surgery. You can read more on our blog, Covering Lipedema, on Coverlipedema.com.
Pay It Forward Program
We believe that our covered members are our best representatives for new members. So, we have created the Coverlipedema.com Pay It Forward Program. It is available only to members we have deemed to be covered through the Coverage, Appeal, or Network Processes. It provides a referral fee of $100 for each new member referred to us, up to five new members for a maximum of $500. The new member must include your name in their sign-up form when they join. The Referral fee will be paid after at least 30 days of membership of the new member. We reserve the right to disallow the payment of any referral fee if we believe that it is part of any activity that is suspicious or may be an abuse of the Pay It Forward Program.
What Should You Do Now
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. Even with better insurers, you will need a few months to get everything together. So, 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.
If you are a Coverlipedema.com member, you should continue to work on your coverage and appeal packages. Now is not the time to procrastinate. If you can get covered in the last quarter of the year, your surgeries will most likely take place over next year. This will allow you to maximize your deductible and your out-of-pocket cost limits.
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. Also, take advantage of our Pay It Forward Program.
For Your Best Opportunity for Fair Coverage, Always Remember:
- Choose a competent network surgeon.
- If you don’t have a competent network surgeon, choose only an out-of-network surgeon who is a board-certified plastic surgeon and who actually wants to cooperate with insurance companies.
- Never, ever, choose a surgeon who requires that you pay-in-full upfront for lipedema surgery if you have insurance. (Or even asks you for a deposit to reserve your surgery date.)
If you have questions about lipedema coverage, please reach out to us. We are here to help you on your journey to health and wellness.
The Staff at Coverlipedema.com