Choosing Your Surgeon
Who Will Be Your Surgeon?
Your choice of surgeon is the most important decision that will determine whether your insurance will cover your lipedema surgery. Currently, it’s still not easy to get lipedema surgery coverage, and you must choose a surgeon who believes in your right to get your surgery covered. In our opinion, only a few surgeons who are qualified to perform high-quality lipedema surgery are also able and willing to work with insurance companies to obtain your fair coverage.
How To Choose?
There are many surgeons you could choose for your lipedema surgery. Some have flashy websites, an extensive social media presence, and incredible before and after photos. Others, who you have never heard of, have modest websites and no social presence. Some operate in large hospitals and some in a room in their office. Plus, there are so many recommendations on Facebook, but which ones can you trust? How do you choose your surgeon?
First, a Disclaimer
As patient advocates, we can only help you make your choice solely based on insurance and safety related criteria. We make no judgments of the medical or surgical qualifications or outcomes of the surgeons we recommend. Our recommendations are based on our insurance coverage experience with them and on their approach to patient safety. As patient advocates for many years, we urge you to do your due diligence when choosing a surgeon based on your desired medical outcomes. We suggest that you speak with at least two surgeons before making your decision. Also, speak directly and privately with several of their former patients and ask them about their surgery outcomes, their insurance experience and the helpfulness and professionalism of the surgeon’s staff. While before and after photos are helpful, they can be manipulated, and some surgeons will only provide them when you have a consult and will not post photos of patients on social media. Also, take the time to check with the medical board of the state where your surgeon is licensed for any actions, convictions, reprimands or malpractice judgements. We know that choosing a surgeon can be difficult and hope that the following information makes your choice easier.
Board-Certified Plastic Surgeons
For the best insurance experience, we recommend a board-certified plastic surgeon certified by the American Board of Plastic Surgery, which is the only board the American Board of Medical Specialties recognizes to certify doctors in the full range of plastic and reconstructive procedures. We believe that only board-certified plastic surgeons have the years of training and experience to safely and effectively perform lipedema liposuction surgery. For insurance coverage, using a board-certified plastic surgeon provides several advantages. In fact, some insurance companies require using one. Board-certified plastic surgeons are required to perform their surgery in an accredited, state-licensed, or Medicare-certified facility. We recommend only having surgery in a hospital or in one of these facilities, and never in an unlicensed facility or uncertified physician’s office. Some insurance companies also insist that surgery only be performed in an accredited, state-licensed, or Medicare-certified facility at the least. The surgeons that we recommend also insist on proper post-operative observation in an accredited facility to ensure safe outcomes.
Finally, board-certified plastic surgeons adhere to a strict code of ethics and are required to complete continuing medical education, including patient safety, each year.
We do not recommend cosmetic surgeons, internal medicine doctors, OB/GYNS, dermatologists, or others who have not been properly trained for plastic and reconstructive procedures and who have not been board certified to perform those procedures.
Most insurance plans are based on a network of participating healthcare providers. These providers are called in-network, participating, or contracted providers, and you are usually required to use them exclusively. However, only a limited number of in-network surgeons treat lipedema. These in-network surgeons tend to do fewer lipedema surgeries, have scheduling issues, and, even in large hospital systems, are not great with coverage requests and appeals. If you are interested in using an in-network surgeon, please feel free to contact us via our contact form, as we know a few who are willing to follow the correct process for getting insurance coverage.
Since lipedema surgery was not covered for many years, most experienced lipedema surgeons are currently out of network. That means your surgeon cannot bill your insurance and only accepts payment in advance for surgery directly from patients. In turn, patients who submit their surgery claims, even if they are approved, might face much higher out-of-network coinsurance and deductibles and usually much lower claim payments. At Coverlipedema.com, we assist our members with getting out-of-network surgery covered as if it were in-network. We have been successful in most of our cases.
Single Case Agreements
Even with approval to pay in-network coinsurance and deductibles, the insurers could still only reimburse a few hundred dollars because the surgeon’s costs are “too high.” In this situation, your out-of-network surgeon will be able to bill you for the balance due. So, the safest way to ensure the insurer pays fairly and you don’t have surprise medical bills is a Single Case Agreement (SCA).
An SCA is a contract between your out-of-network surgeon and your insurance plan covering your surgeries as if your surgeon were in-network. It lays out all the costs for your surgery, so you know before the surgery what is covered and for how much. Usually, the insurer and surgeon can work out a mutually agreeable rate. Surgeon’s fees under SCAs have typically been over $60,000 for a staged series of surgeries for a patient. Regardless, you are usually only responsible for your in-network deductibles, co-pays, and coinsurance, and those can all be reduced by your maximum out-of-pocket limit. That means that with intelligent scheduling, you may be able to complete all your surgeries in a calendar year for the lowest possible out-of-pocket cost. Usually, surgeons have to lower their fees to negotiate with insurers to make SCAs happen. Because of this, an SCA might not be possible for some more expensive surgeons, or you might have to pay extra for some of their services.
Some surgeons will tell you that they will enter into single case agreements, but, to our knowledge, have signed very few, if any, for lipedema surgery. While we expect surgeons to be ethical, we recommend that you ask to see their redacted SCAs from the past few months (HIPAA compliant, if personal health information is removed). You should also ask to speak with their patients who were covered by insurance. If they are not willing or able to show you these agreements or let you speak with their patients, you should reconsider your choice of surgeon.
Your Working Relationship with your Surgeon and Staff
Your relationship with your surgeon and their staff should be based on trust, respect, communication, and mutual understanding. They should provide you with proper documentation in a timely matter, never pressure you to schedule surgery and pay up-front before approval, and easily sign single case agreements with insurers. They shouldn’t force you to place large deposits to secure surgery dates before getting your insurance approval. They should never tell you that they “have to bill you more if you use insurance” or that “it’s not worth trying to get coverage.” Both of these statements are not true. They should never hold your surgical plan and notes hostage by refusing to give them to you so they can submit the request themselves, especially if they are out of network. Many highly qualified surgeons cooperate with insurance companies. There is no reason to use one who doesn’t have a good track record of working with insurance.
In light of all the above, to give you the best opportunity to have your surgery covered by insurance, we recommend the following surgeons who are either network providers or board-certified plastic surgeons with significant lipedema surgery experience and who have signed numerous single case agreements with multiple insurance companies:
Dr. Karol Gutowski & Dr. Andrea Martin | Chicago, Illinois | drgutowski.com
Dr. Boris Volshteyn | West Long Branch, New Jersey | Atlantic Surgical Associates
Dr. Liza Kim | Sacramento, California | 916-705-2798 | website coming soon
Dr. Thomas Hagopian | Atlanta, Georgia | Peachtree Plastic Surgery
Dr. Omar Beidas | Orlando, Florida | Advent Health | contact info and website coming soon
Dr. Joshua Elston | Gig Harbor, Washington | Elston Clinic
Dr. Adam Schaffner | New York City | Plastic Surgeon NYC
Dr. Mark Domanski | Fairfax, Virginia | Bluemont Plastic Surgery
These recommendations are based solely on our working relationship and experience with these surgeons with insurance coverage and patient safety. We receive no compensation, financial or otherwise, for our recommendations. As patient advocates with a family history of lipedema, we only recommend surgeons that we would recommend for our loved ones.
I cannot say enough good things about my experience with Cover Lipedema. They are an ally and partner in care that has knowledge, experience, contacts and resources that a patient could never have.
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This page was updated on 22 October 2021