Since Coverlipedema.com started working with lipedema patients over six years ago, we have lowered our membership fees from over $3,500 to under $1,400 for prior authorization and appeals with an out-of-network surgeon. Although we have consistently reduced our price, we have continued to deliver incredible value with over 800 women covered for tens of millions of dollars of lipedema surgery.
Focusing on Prior Authorization
However, the initial $299 member fee does not provide enough resources to ensure that women are quickly covered. As insurance companies adjust to our successful tactics, we are finding that we must devote more time to the prior authorization process to avoid appeals. While we have successfully appealed most denials, we have decided to focus on prior authorization because some independent reviewers have been using the Standard of care for lipedema in the United States to deny all surgeries except for the legs. Increasing our focus on the early stage of the process will allow us to win coverage faster, reducing the time between beginning with us and having surgery. We also find that because our current fee is so low, women who are not serious about our process or do not fully understand our commitment to working with only safe, effective, and insurance-friendly plastic surgeons have joined. These unmotivated members are distracting us from advocating for our members who are truly committed to safe and effective surgery. We are also experiencing backlash from fringe non-plastic surgeons as more women join Coverlipedema.com. The harassment of us and the surgeons we recommend, combined with threats of frivolous lawsuits by certain lipedema doctors, are the main reasons we are moving forward by focusing on ensuring that the surgeons we recommend have a quick and steady stream of motivated and fully approved patients. After six years of advocating for over 800 women to have their surgeries fully covered, we have demonstrated that full coverage for lipedema surgery is possible and can be done regularly with our assistance.
Our New Initial Fee and Benefits
To allow us more time to ensure that patients get fully covered and that surgeons are paid fairly so they can continue to treat this disease, we have decided to return to our original model of working closely with fewer members committed to having surgery with a plastic surgeon. As a result, we are combining our Coverage Process and Appeal Process memberships into the Coverage Plus Process Membership. Starting June 1, our initial membership fee will be $1,399. In addition to the current benefits of membership, the Coverage Plus Membership includes these additional benefits:
- A Personal Regional Ambassador to help ensure meeting coverage requirements and gathering documentation quickly. Both new and existing Coverlipedema.com members will have an online chat forum where they can get answers to common questions and ask new ones.
- More proactive outreach by Coverlipedema.com before prior authorization submission to insurers, employers, or regulators to express concern about inconsistent reviews of lipedema requests compared to other diseases. This will help prevent the refusal of insurers to issue prior authorizations, as they have been doing lately to force women to pay upfront.
- Outreach after denials that have no medical basis or are a misinterpretation of plan policy to prevent having to engage in the risky appeal process. If appeals are needed, more pressure to approve surgeries on the internal appeal level to avoid external appeals and poor-quality reviewers.
- Assisting every approved member with ensuring that their surgeries are properly arranged, including correct surgical units and time needed to complete surgery.
- Assisting with payment issues following surgery
A New Network/Single Case Agreement Process Membership
The Coverage Plus Process Membership includes appeals of full and partial coverage denials from the peer-to-peer level through internal and external reviews without extra fees. As part of the higher initial fee, we will be more proactive about coverage and access to out-of-network providers. Still, if insurance companies refuse to grant an out-of-network exception and negotiate a single-case agreement, members will need to upgrade their membership to the Network/SCA Process. Because we will need to spend significant time ensuring a network exception and single case agreement, there will be a $499 upgrade fee. Coverlipedema.com membership will expire in a year unless there is good reason to delay the process, as we want women to be motivated about getting covered and moving forward with surgery. Of course, our new members will be covered by the Coverlipedema.com Guarantee.
These fees are still a small fraction of the $75,000 or more in surgical costs we get covered by insurance or what fringe physicians force women to pay upfront in cash, hoping to get reimbursed one day. We will continue to offer services to Medicare and Medicaid plan members at our current rates.
New Pricing Takes Effect June 16th
To give us time to transition our processes, which will involve far more upfront advocacy and a reorganization of our workflow, our existing rates for new Coverlipedema.com members will remain in place through June 15, 2024. The $1399 price will not be active until June 16th. We will continue to fully support our Coverage Process members and will apply the prior network and appeal rates as needed. We will continue to work with all our members to get their safe and effective lipedema surgeries fully covered.
The Coverage Plus Membership will Increase our Effectiveness
Someday, a lipedema diagnosis will be made by a primary care provider, and patients will be sent to a properly trained surgeon who easily accepts insurance. Patients will no longer have to search for lipedema treatment options on the internet, where they can become confused and misinformed. When that day arrives, our mission of having lipedema be covered like any other disease will be achieved, and we will not be needed anymore. We look forward to that day. Until then, we will continue to be the most effective advocates for ensuring safe and effective lipedema surgery fully covered by insurance.