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The Reimbursement Landscape for Reduction Mammaplasty: Variability Among Third Party Payers and Opinions of 757 Board Certified Plastic Surgeons
Jordan D. Frey, B.S., Peter F. Koltz, M.D., Howard N. Langstein, M.D..
University of Rochester Medical Center, Rochester, NY, USA.
Insurance coverage of reduction mammaplasty (RM) procedures is incongruent with current clinical evidence. The variability of insurance carriers’ criteria for coverage as well as U.S. plastic surgeons’ interactions within the current climate have not been evaluated. The purpose of this study is to both assess the pattern of coverage requirements by insurance carriers’ characteristics and examine the relationship between plastic surgeons and insurance carriers’ coverage of RM. Further, given the evolving landscape of the American healthcare system, this study endeavors to define the influences shaping current opinion in the field of plastic surgery, specifically as related to RM.
Fourteen regional and nationwide health insurance carriers in addition to Medicare were characterized by region, operation classification, and market share. RM policies including weight resection requirement, patient age, and necessity of trial of conservative therapy were recorded. A multiple-choice survey was created and distributed to all registered members of the American Board of Plastic Surgeons regarding RM. Measures of central tendency were used as appropriate to analyze responses.
The majority of insurance carriers require a minimum resection weight, an age minimum, and a conservative therapy trial. Seven hundred and fifty-seven board certified plastic surgeons responded to the survey. 74.1% of responding plastic surgeons were in private practice while 14.8% were in academic practice. 62.1% perform approximately 11-50 RM procedures per year. 75.9% of respondents believe that only some RM procedures should be covered procedures while 20.5% and 3.6%, respectively, believe that the procedures either exclusively should or should not be covered. 55.2% believe that the amount of tissue resected should be used as a criterion for coverage by insurance carriers. 26.8% believe resection weight is the most important criterion for coverage while 64.1% feel that symptomatology is most important. 56.6% state ≥500g/breast resection weight is required for coverage by insurance carriers in their region. 71.3% believe this weight should be <500 g/breast. In a scenario where resection weight is very close but inadequate to pre-approved weight, 45.6% would not remove additional tissue risking non-payment; 32.7% would complete the procedure and, if payment is denied, would inform the patient that payment would be out-of-pocket. 30% of respondents have had at least one claim denied after surgery was performed in the past year. 83.9% believe that if RM was uniformly uncovered, patients could not afford and would not elect to undergo this procedure.
Coverage criteria for RM are not uniform and vary by insurance carrier characteristics. The majority of U.S. plastic surgeons believe that symptomatology is the most important factor determining medical necessity, and that resection weight should be included as a criterion for reimbursement. The resection weights commonly required for coverage do not agree with surgeon opinion of what this weight should be. Further, rejection of RM claims is frequent, underscoring the need for coverage requirement revisions. U.S. plastic surgeons believe that RM should not uniformly become a cosmetic procedure only; it is therefore imperative that plastic surgeons work to ensure its fair compensation in the evolving healthcare system.
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