You’ve had your consultation with our surgeons and a surgery date has been coordinated for you. Now what? It’s time for our surgery scheduling staff to ask your insurance company for Pre-Certification and/or Pre-Authorization. If you’ve had a diagnosis of breast cancer, it’s a little more straightforward to obtain than if you are having a preventative mastectomy due to genetic factors.
First, if you haven’t had a mastectomy, your breast surgeon needs to do their part by requesting pre-authorization/pre-certification for that portion of the procedure. Once that is approved, we can contact your insurance company and provide information to obtain the same for your breast reconstruction surgery. If it’s not a company that we are in network with or a smaller company, they may have never encountered a patient who is requesting to have microsurgical breast reconstruction and may be unfamiliar with the coding that is used to most accurately reflect the time, complexity, and expertise required to perform these procedures successfully. In those cases, it takes a little bit longer to receive the authorization, but we rarely encounter a commercial insurance company that we cannot work with to make sure you receive the surgery you are requesting.
After 22 years of performing these types of complex microsurgical breast reconstruction surgeries (DIEP, GAP, SIEA, PAP, etc.), we’ve become experts at navigating this process. We are in network with most major insurers like Blue Cross Blue Shield, Aetna, Cigna, United Healthcare, Humana, and more. We don’t want you to have any surprises in the billing process after your surgery, so we assure that our preferred hospital and any ancillary services we use are participating in the same networks.
Sometimes there are smaller procedures like abdominal vessel delay, tissue expander removal, or preliminary breast lift/reduction for nipple conservation that happen prior to DIEP breast reconstruction. Those take a bit of explaining to your insurance company and they don’t always get approved on the first submission. If this happens, we schedule a Peer-to-Peer review with your insurer’s medical director to obtain authorization for you. This usually resolves any problems, and we are ready to proceed.
We also need to obtain authorization for your pre-operative MRA. This scan is a “map” for us that locates the most viable blood vessels in your abdomen on which to base your breast reconstruction. This is not the “normal” reason to have a scan like an MRA and many times we must go through the same Peer-to-Peer process to obtain approval.
Once all these pre-certifications/authorizations have been obtained, it is time for us to move forward with ordering everything that you need to have completed prior to surgery. Our next post in this series will focus on what you and our staff need to do to prepare you for your DIEP breast reconstruction surgery.
– Gail Lanter
Note: In general, government-based health plans like Medicare, Medicaid, and Tricare do not have or recognize the series of codes in their fee schedules that we use in private practice – we call them “S” codes – and we suggest the patient contact a teaching hospital or employed physician group for their initial consultation and subsequent surgery.