Frequently Asked Questions
Should I just let my surgeon handle insurance coverage and payment?
You must be proactive in your health care. Your success rate will be much higher if you are knowledgeable and involved in your insurance coverage process. A surgeon’s office manages care for many other patients and may not be able to give your coverage request sufficient attention. For many procedures, a surgeon’s office only has to submit a simple request that is quickly approved. However, lipedema surgery requires much more than a simple request to get covered. Coverlipedema.com helps you create a comprehensive, independent coverage request package that you need to get covered. Additionally, there are other documents you need to gather, like a functional capacity evaluation, support letters for your diagnosis, and proof of conservative measures. These documents are not usually handled by a surgeon’s office and are better obtained and managed by you.
Of course, you will be working with your surgeon to obtain certain documents like the surgery plan and surgeon’s notes. Some surgeon’s offices are better than others at supporting patients seeking insurance coverage. We’ll provide guidance on how to make sure that your surgeon provides you with timely and correct documents.
To be frank, surgeons have little incentive to help you get insurance coverage. It is much easier for them to collect the full amount of their fees from you before surgery than to collect your coinsurance and copays and wait for an insurance company to pay them a reduced rate 30 days or more later. It is also easier for them to convince you to pay upfront and promise to help you submit a claim, hoping to be reimbursed fairly, than to take that risk themselves. Understanding this reality will make you a better-informed advocate for your interests.
How long does it take to get my surgery covered?
If your plan covers your surgery without an appeal, it can take about six weeks to get approval. If you need to appeal your case, it could take as long as four months.
How much work is involved?
We make this as easy as possible for you. Most of the forms you need for getting coverage are provided. You will need to fill them in, which should take a few hours, and then coordinate with your surgeon to get supporting letters and exam notes. We also provide draft letters that you can use to help the surgeons complete. Regardless, you must have a complete lipedema diagnosis and surgical plan before you can apply for coverage.
If you need to appeal a coverage denial and have done a good job with your documentation, it can take 4 or 5 hours to complete your appeal. We also provide tips on additional steps you can take with your employer or the independent review organization to maximize your chances of winning your appeal.
If you have to dispute poor payment by a plan through a separate appeal, that also can take 4 to 5 hours plus phone calls and emails to ensure that claims are processed and paid.
Why do you charge a fee for your services?
Just like your surgeon or any other professional, we have years of experience doing what we do. We have worked many years as health advocates generally and with lipedema, specifically for the past two years. Our interactions have cultivated connections at the highest levels with insurers, state and federal regulators, and large employers that make the process smoother and fairer for you. We have advised large health systems for years and have educated physicians on rules, regulations, billing, and coding. Our experience and success with lipedema coverage, appeals, and out-of-network approvals cannot be matched.
While a surgeon’s staff or other advocates might be able to submit a coverage or appeal request, we have the knowledge and connections to make the process fairer and more successful for you. We work nationally with patients and insurers daily and use our knowledge and data as leverage to expand coverage, access, and fair payment for all patients.
When you work with us, we are available to answer your questions as you gather supporting documentation. Our experience can help you avoid the typical reasons why coverage is denied. We review both coverage and appeal submissions before you submit them. We refine our templates based on new decisions and our discussions with insurers and independent reviewers. Our approach and success with appeals is the result of pursuing earlier independent reviews and ensuring that the reviews are fair. We spend time reviewing and collecting coverage, appeal, network, and payment determinations to proactively address insurer concerns and create precedents to ensure fairer and more consistent insurer decisions.
Without insurance coverage, your cost for typical lipedema surgeries can be over $50,000. With insurance coverage, the cost can be as low as your maximum out of pocket cost, which could be less than $5,000. With the current situation of lipedema surgery coverage, we believe that the best opportunity for you to get your surgeries covered is to use Coverlipedem.com. Our fees are a small investment for great potential savings. Additionally, we offer a guarantee which you can learn more about in the About Us menu.
What is your success rate?
For Members who have plans covering lipedema (Aetna, Anthem, and many small plans, including state Blue Cross Blue Shield plans), there is a 100% success rate. Sometimes these plans will mistakenly deny coverage, and you will need to reach out to them, but we prevail eventually. Most other plans, may require appeals. If you have to appeal your claim, you have an 85% chance of winning coverage on external appeal provided you have good documentation of your diagnosis, conservative measures, and the impact lipedema has on your function. We provide strategies to maximize your chances and can assist if you have a poor quality review.
How much can I expect my insurance company to pay for my surgery?
We have made amazing progress in getting lipedema surgery covered in the past 18 months. 80% or more of patients with documentation of their diagnosis, three months of conservative measures, and a functional capacity evaluation can get coverage and payments for surgery ranging from $8,000 to $16,000 per surgery. Some plans pay better than others and how much you get paid can depend on your geographic location.
Can I get help if I need it?
Yes. We are available to help you and can answer simple questions via our contact form. For the rare, complex questions that require significant time and effort to answer, we offer individual consultations at an hourly rate approved by you in advance. Either way, don’t hesitate to ask any questions. Our mission is to help you get covered and we are here to help you.
…I got approved for approximately 60k in surgery from CIGNA with the help of Cover Lipedema. They made sure that I was covered after a poor quality review and, as with every women who gets covered with them knows, their fees are a small price to pay for 60k in surgery.
Learn about Insurance
Please visit the information pages specific to your plan for more information on your insurance coverage.
Choosing Your Surgeon
Please click below to learn about choosing a surgeon to give your the best opportunity for insurance coverage.
This page was updated on 12 March 2021