Many Coverlipedema.com members choose to use an out-of-network surgeon for their lipedema surgeries While there may be many good reasons to make this choice, it is important to understand the impact of this choice on insurance coverage to make an informed decision about your treatment.
Insurance Networks
Commercial insurance companies contract with surgeons to provide services for their members. These surgeons are usually referred to as being in-network or participating providers. They have agreed to accept lower fees in exchange for the insurance company referring its members to them. In turn, insurance companies offer lower cost sharing and copays to their members when using one of these network surgeons. Using an out-of-network surgeon will usually cost much more than a network surgeon, including higher deductibles and copays. Some insurance companies will not even cover services with an out-of-network surgeon.
Most Lipedema Surgeons are Out of Network
Unfortunately, most lipedema surgeons are out of network. While we highly recommend using a network surgeon for the ease of insurance coverage, we recognize that there are many valid reasons for you to choose an out-of-network surgeon. They may be closer or available much sooner than a network surgeon. An out-of-network surgeon may be the best choice to handle your combination of issues.
Network Exceptions
Fortunately, we can help patients overcome the added cost of using an out-of-network surgeon by requesting a network exception. Depending on your insurance company, this may be called a clinical gap exception, out-of-network exception, network insufficiency exception, or gap waiver. This exception asks for the insurance company to treat the surgeon as being in network.
Network Exceptions are not Easy
Network exceptions are not normal things to get, and insurers do not give them easily. We have been able to get hundreds of network exceptions and are successful about 75% of the time. Usually, Insurance companies will state that they have network surgeons who can treat this disease. The list of surgeons is usually incorrect, often including some who do not even treat lipedema. We know many of the network surgeons that insurers would suggest and keep data on their lack of interest or experience in treatment. Usually, we can win an exception at this level by proving the network insufficiency. If we need to raise the level of dialog, we also have connections and experience working with state and federal regulators, and employers, including over 100 Fortune 500 companies, on lipedema surgery access. This allows us to put pressure on the insurance company to change its decision. If we cannot get an exception, we can help you transfer your approval to a network surgeon. We know several surgeons in multiple networks who treat lipedema safely and effectively but want to keep a low profile. We could facilitate a transfer for you with the insurer, which can often be done in a few days.
Single Case Agreements Protect You
Even with a network exception, you are not fully protected. You may still have to pay upfront and file a claim afterward to get reimbursed less than you paid the surgeon. Your insurance company could pay only a portion of your charges, leaving you responsible for the balance of your bill. This is called balance billing, and it is allowed if you are using an out-of-network surgeon. The best way to know exactly what you will pay is to have your surgeon sign a one-time contract that explicitly sets the fees with the insurance company. This is usually called a single-case agreement (SCA). In essence, it allows you to use an out-of-network surgeon with all the benefits and costs of a network surgeon. As you would expect, this is not an easy thing to do and, frankly, insurance companies do not like them. Since the negotiation takes place between your surgeon and your insurance company, it is vital that your surgeon is willing and able to make single-case agreements. You must have the right surgeon. We also monitor the single case negotiations and get involved if negotiations stall or payment rates are too low because we have more data and arguments than the surgeon does as to what has happened historically and nationally.
This is especially the case if your surgeon has not negotiated before with the insurer. We also help get the needed extensions for approvals because lipedema surgery can take many months to accomplish and we want the agreement to cover all the planned surgeries. This is important to avoid future denial risk. We have helped hundreds of women have their surgeons sign single-case agreements for their surgeries.
We Can Help You Overcome Out-of-Network Challenges
Although choosing an out-of-network surgeon can make insurance coverage more difficult to obtain, we can help most lipedema patients choose the best surgeon for safe, effective, and fully covered surgery. We are fully knowledgeable of and highly experienced with network exceptions and single-case agreements. Hundreds of our members have had their out-of-network surgeons fully covered for all their lipedema surgeries.