Let's Talk About Basic Insurance Coverage: The Good, the Bad, and the Ugly
I'll try to make this NOT boring.
Hi Everyone!
Before I get started, I have a new website, www.getyourlipedemaapproved.com. Check it out!
As some of you may already know, when I got diagnosed only two years ago, I immediately started my quest for liposuction surgery.
I quickly discovered that Lipedema treatment has historically been denied coverage by insurance because Lipedema hasn’t been recognized as a medical condition.
As a nurse case manager who’s worked in the insurance industry for over 15 years, I knew I could still easily lose the battle for liposuction coverage. The stakes are high, and insurance does everything possible to deny any medical treatment outside the norm.
I know the good, the bad, and a lot about the ugly of medical insurance. So let’s get started! We’ll go backward, starting with The Ugly, so we have the good part at the end.
The Ugly
Honestly, I never thought I’d have a legitimate medical condition that wasn’t questioned by medical insurance. Then Lipedema came along, and I realized very quickly that this disease was considered cosmetic and “not medically necessary,” and therefore denied coverage.
As of this writing, unless you’re under one of the big-named insurance plans (Aetna, UHC, BCBS, for example), that has plan language for Lipedema treatment, insurance will likely not have Lipedema treatment addressed in their benefits. (This is starting to change, thank goodness!)
My own health insurance, a self-insured regional PPO plan, did not have any plan language in place when I started on my journey for liposuction coverage.
Most insurances won’t list benefits if they aren’t seen as a standard procedure for a disease. And some procedures, like liposuction, are put under the infamous blanket clause “considered cosmetic and not covered.”
When you start working with your insurance company, you’ll find they give you the wrong information, pass you around from department to department, and keep you in an eternal loop of misinformation, nor responding at all to your questions. They stall in any way possible to delay your treatment in the hopes you’ll give up completely (I’m not kidding!).
Since physicians are the ones who send in preauthorization requests, they typically bear the brunt of the ugly part of insurance. However, plastic surgeons don’t normally go through insurance for payment (instead, they privately bill their patients). That means Lipedema women send in their own preauthorization requests instead. And that means you’ll see the very ugly side of insurance when trying to get coverage.
The Bad
The US healthcare system is the most expensive in the world. Peter G. Peterson Foundation describes the fiscal challenges of healthcare in our country:
“In 2021, U.S. healthcare spending reached $4.3 trillion, which averages to about $12,900 per person. By comparison, the average cost of healthcare per person in other wealthy countries is only about half as much.” PGP Foundation
To add to this, governmental healthcare coverage is only available to those who are elderly, disabled, or financially at the poverty level. All others aren’t covered unless we privately pay for our insurance, either through our employer at our job or by individually purchasing insurance. Insurance premiums are costly, and many people, including the “working poor,” can’t afford insurance and will go without it.
Health insurance also gets to decide what they will and will not cover. Most insurances require preauthorizations for almost everything, from prescriptions to MRIs to surgeries. The bureaucratic red tape is thick, and it can take months to years to get medical care.
It took me an entire year to get my Lipedema surgeries, and I’ve talked with women who have been trying for years to get coverage for liposuction surgery without success.
Because the system is so convoluted, we must be persistent in obtaining the medical care we need.
The Good
After all of that, you may be asking yourself, “What’s so good about insurance?”.
Regardless of how much insurance costs and how hard they make it to get treatment, insurance plans do have laws, rules, and regulations to follow. These entities protect our patient rights and are a place to go if we feel we’re being treated unfairly.
We also have the ability to change the system. Change happens when a large population pushes back. For example, this has happened with breast cancer. Women used to be denied coverage for breast reconstruction/implants after mastectomy. Because of federal law, the Women’s Health and Cancer Rights Act of 1998, insurance now must cover breast reconstruction with a mastectomy, which is otherwise considered a cosmetic procedure.
Other conditions and diseases have gained momentum (such as Lipedema) and have had class-action lawsuits won against several large insurance plans that refuse to cover needed medical care.
It’s unfortunate that the pushback has to be so drastic. However, this is the good part; it works when people band together to change a system that’s unwilling to keep up with the times.
This change for Lipedema coverage starts with you and me and all of the other women who are willing to go through the steps. This not only helps us, but it helps our daughters, our nieces, and our granddaughters when it’s time for them to seek the same medical care.
Take care,
Michelle
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Go to my new website: www.getyourlipedemaapproved.com, and make an appointment with me to discuss where you are in your Lipedema journey and what help you need (diagnosis, conservative care, lipo surgery) for treatment.