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The following tips and suggestions are based on experiences we have had. For more complete information regarding your insurance coverage, review your insurance benefits.
- If you have an HMO all specialists and some diagnostic tests need referrals from your Primary Care Provider. It is best to talk to the person who handles the insurance referrals in the Primary Care Provider's office. Let them know which physician you will be consulting or what tests are scheduled. Be sure to keep record of details such as date, time, to whom you spoke, and the authorization number for the appointment. A partner can do this for you. If you have multiple insurance coverage be sure the Primary Care Provider notifies them all.
- Some insurance companies require second opinions regarding mastectomies.
- If you have Medicare or Medicaid, consult your case manager.
- If for any reason the insurance company refuses to pay, a good recourse would be to consult your local legislator.
- In some states breast reconstruction is not covered. Other states such as Pennsylvania, have laws that require insurance companies to pay for breast reconstruction up to six years after the mastectomy. This includes reconstruction surgery on the original mastectomy and surgery of the other breast to create symmetry.
- Prophylactic and nipple reconstruction may not be covered by insurance unless your surgeon writes a letter of medical necessity.
- Always check with your Primary Care Provider and surgeons' offices. Their staff is trained to help you obtain the correct referrals and answer insurance questions.
- Remember, the responsibility is yours to notify the correct parties and obtain referrals. At a time of such emotional stress and decision making, it is helpful to have someone such as a family member help you with this task.
- Most medical facilities have financial advisors and utilization review managers who will also be of help.
- Financial worries may add to your stress, but they can be worked out and should not be a reason to avoid the surgery or procedure of your choice
Excerpted from the SHOWME Book/2nd Edition: A Photo Collection of Breast Cancer Survivors' Lumpectomies, Mastectomies, Breast Reconstruction and Thoughts on Body Image; 2001 The Milton S. Hershey Medical Center; used by permission
For more information, contact the
PA Deptartment of Health Bureau of Managed Care, www.health.state.pa.us
or call toll-free: 1-888-466-2787
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