Over the past four years, Coverlipedema.com has successfully obtained lipedema surgery insurance coverage for many Medicare and Medicaid patients. However, we only currently accept Medicare and Medicaid patients on a case-by-case basis, including Medicare Advantage members. Unfortunately, we have been forced to no longer work with many of these patients due to insufficient payment of surgeon fees for lipedema surgeries. However, since we are committed to helping all women get their lipedema safely and effectively treated, we have found some options for women with these insurance plans.
Why This Problem Exists
Normal rates for lipedema surgery vary from $8,000 to $10,000 per procedure. Medicaid, Medicare, and Medicare Advantage Plans pay surgeons far below market rates for lipedema surgery. Those plans may pay as little as $2,000. Although the plastic surgeons we recommend care about lipedema patients, being reimbursed only $2,000 for a three-hour surgery with significant pre and post care is not fair. As a result, it is almost impossible to find a board-certified plastic surgeon in private practice willing to accept Medicare and Medicaid patients.
Our only exception is certain large employer Medicare Advantage retiree plans. We have been able to get the employer to force the insurance company pay fair payment rates enabling coverage.
Surgeons Who Accept Medicare and Medicaid
Of all of our recommended surgeons, only Dr. Omar Beidas, a hospital employee, will accept Medicare for his fees. Unfortunately, he is not available for consultation until 2023. We hesitate to recommend any other surgeon employed by a hospital except for one with limited capacity for Minnesota residents only and Dr. Graham Schwarz at the Cleveland Clinic, who only works with women with a BMI under 35. Although university-based surgeons may be willing to accept a low payment, we generally do not recommend them. In our experience, they do not have the proper training for large-volume liposuction. In the surgeries we have seen, they either have removed too few liters or have performed invasive and unnecessary excisions on entire legs. However, if you find a university-based surgeon who seems to be able to provide effective surgery, please contact us for assistance. University-based surgeons and their staffs are not experienced in the intricacies of getting lipedema surgery covered. Relying on their assistance for insurance coverage will likely lead to denials and lengthy delays.
Partial Medicare Coverage Approach
Regardless of the challenge, some women with Medicare might still want to pursue coverage to obtain partial payment and reimbursement. We have an approach for these patients. First, the patient can only work with a surgeon who operates in a hospital. Then, we separate the payment of the surgeon’s fee and the hospital fees. The surgeon will bill the hospital fees as with any Medicare procedure. We have been able to consistently get hospital fees covered. The patient pays the surgeon’s fee upfront. Although we usually never recommend paying in advance, this would be your only option. With our assistance, the patient submits a claim to Medicare, but the reimbursement will be around $2,000 per surgery. If you pursue this route, we strongly recommend you join Coverlipedema.com to ensure that you are not responsible for either the hospital or surgeon’s fee if this approach is not done correctly. There are also some requirements for preauthorization that must be handled properly. If you choose this partial Medicare option, we will not charge for an appeal, if needed, since you are getting back a much lower amount for the surgery.
Of course, this approach would not be available for doctors who charge exorbitant surgery and facility fees, are not allowed to bill Medicare for services or facilities, or do not have hospital privileges.
Medicare Insurance Alternatives
Another option for those on Medicare is getting a job offering commercial health insurance. If you are disabled and the employer has more than 100 employees, that employer insurance plan becomes primary. If you are over 65, there must be more than 20 employees for the plan to become primary. We are happy to advise on the best options if you schedule a strategy consultation with us.
Options for Women Covered by Medicaid
For those with Medicaid, payment rates are also a concern, but we have had some success recently. We are confident we can get you covered, but the payment rates for out-of-network surgeons and approvals for out-of-state agreements have been challenging. If you are willing to try, knowing that the success rate might be lower, you are welcome to join Coverlipedema.com. We will provide a free appeal if needed, but a network exception, which requires considerable work, would still be between $500 to $1000 if needed. Of course, our Coverlipedema.com Guarantee applies here as well. We won’t give up trying to get you covered unless you give up.
Some women with Medicaid choose to get employer-based insurance coverage or use the healthcare exchange in their state to get a new insurance plan to cover their lipedema surgery. We are happy to advise on the best options if you schedule a strategy consultation with us.
Help All of Us Find Safe and Effective Lipedema Surgeons
As patient advocates, we want everyone to have access to safe, effective, and fully covered lipedema surgery. To help us find more lipedema surgeons, we are offering free Coverlipedema.com memberships ($399 value) for women who find their own plastic surgeon who does not currently work with us. These new surgeons have to meet our criteria for safety and effectiveness. We only recommend plastic surgeons who perform surgery in licensed facilities, preferably with higher volumes, including a supervised overnight stay. We know there must be more plastic surgeons willing to treat lipedema. We suggest calling bariatric programs close to you and asking if their plastic surgeon does skin excisions on bariatric patients. Because most bariatric surgery patients are women, it’s very likely the plastic surgeon has seen lipedema, and higher BMIs do not concern them. Next, call the surgeon’s office and see if they are willing to treat lipedema. If they are, then we recommend you contact us to talk with them further. You don’t need to ask about insurance at this time because some surgeons are willing to work with Medicare and Medicaid patients at lower rates early on as they build their practice in this area.
We Wish There Were Better Options
We wish there were better options for women covered by Medicare, Medicare Advantage, and Medicaid. Although we have been successful in the past in getting lipedema surgery covered by these plans, we know that, currently, the challenge is almost too much to overcome. Coverlipedema.com will not abandon women with these insurance plans, but we will not take money from women unless we are certain we can get them covered. So, visit Coverlipedema.com, read our blog, Covering Lipedema, like our Facebook page, join our private Facebook group, or follow our Instagram to keep informed about the latest news on lipedema surgery insurance coverage. We will continue to use our expertise and resources to try to expand insurance coverage for all women who suffer from lipedema.
Please share this widely as too many women are desperate and using their savings or borrowing money for surgery when there are better options. If you want to discuss your situation with us and think one of our options above might work for you, please schedule a strategy consultation with us.
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I appreciate your having taken the time to explain all this. I am in the thick of it and it is good to know what the heck is going on.
It is unfair that a retired woman over 65 has such a hard time getting coverage for a horrible condition that could eventually put me in a wheelchair.
It’s age discrimination and gender discrimination.
Thank you for working for us
I’m with you Rebecca. It’s not right.
You’re exactly right. I’m in the same boat