IT’S THE LAW

 

For insurance intents and purposes, breast reconstruction is in the cosmetic category. To restore symmetry after massive tissue removal of a mastectomy, a woman is referred to a plastic surgeon, a member of the breast surgery team to undergo the recommended procedures.

It is federal law that insurance covers reconstructive costs after a mastectomy, however just a head’s up it is the patient’s responsibility to follow up on all the numerous accounts in regards to the billing aspect. Due to many discrepancies within the insurance companies make sure the hospital’s services are inside your insurance plan coverage. In 2014, my deductible was met with the first biopsy.

The Women’s Health and Cancer Rights Act of 1998 requires all group health plans that pay for mastectomy to also cover prostheses and reconstructive procedures. In addition, Medicare covers breast reconstruction, while Medicaid coverage can vary from state to state. Government- and church-sponsored plans are not necessarily required to cover reconstruction, so you may need to check with your plan administrator.

Even if you’re covered, it’s still possible to run into problems, especially in certain situations: for example, maybe you’ve chosen a newer type of reconstructive procedure, you’re having surgery to create a more balanced appearance, or you need a complete correction of a past reconstruction. Coverage also can be an issue if you want to use a plastic surgeon who is outside your health insurance plan’s network.”[1] 

Expenses of surgeries that a patient has the right to receive still has to be approved by the insurance underwriters. That is not the responsibility of the patient, but the patient’s nursing advocate scheduling her upcoming necessary procedures. Generally, the contractual obligations between the hospital and those insurance accounts do not prohibit the necessary procedures to be performed in a timely manner. Often a breast cancer patient can participate in clinical trials to cut costs of her treatment. That was not the case for me.

KU’s financial department was very helpful scheduling for our payments, in the thousands after my first surgery, hopefully rather than disputes you’ll get the support you need. Although the financial office worked with us, it still felt like we sacrificed not owning a newer vehicle which we needed but as it was were stuck driving the old jalopy truck, forever and again biting our lip as Ed played grease monkey mechanic just to get back and forth to work. Granted, I love my ‘96 Jeep Grand Cherokee (yeah i’s twenty years old 197,400 miles) unbelievably comfortable on the highway and tough as a tractor in the snow.

With obligations to pay my medical bills, it was a stretch to even dreamily hope to save money for a better truck for my husband — that didn’t look like some old rustbucket from outa a backhills junkyard. So I felt really guilty whenever Ed changed a flat tire (no spare change for new tires either). At least it doesn’t have duct tape holding the taillights on. He’s a hard worker and so deserves a new truck — a badass truck — like his co workers. We weren’t holding our breath.

For us and millions of folks, that unpaid amount after insurance pays is still very difficult. We were lucky we didn’t have a car payment, however we kept our heads above water with a savings plan through Ed’s payroll, which partially paid the percentage of surgery cost and my medications expense.    

In regards to insurance, being able to take generic is a huge deal. Many cancer medicines are not available in off-brand names. I speak for myself, thankfully Tamoxifen is a low cost drug. Drugs listed inside the insurance plan’s network is easily verified with a phone call.  

Once my treatments began, the bills started filling up the mailbox and we set up a revolving online account. Never once did our financial difficulties based on my breast cancer lead to arguments. Not once did my husband ever give the subtlest accusation that it was anything under my control or preventable so that we could drive a better truck or afford a vacation or move to a bigger house. Of course we wanted those things. But my health was our top priority, not nice things. For that matter, we knew after my mastectomy, we gained the time to strive for the other.  

Taking persistence but being stubbornly attentive with my breast reconstruction debt slowly whittled down the balance week by week. Our insurance plan was such that one surgery put our payout up to the maximum, eliminating further co-pays and hospital bills for the rest of the year.  We kept up payments and were in constant contact with the administrative office, a huge portion of our debt was simply written off by the hospital. It was called ‘absorbed’. We were shocked although grateful; administrations don’t consider that practice a liability. Thereby not qualifying your credit as negative in black & white.

There are not typically hidden fees in the billing process, unlike mortgages. All this points to a good possibility it will only benefit her financial good credit to push and keep on it to appeal to hospital administrators to ease that awful debt burden. It’s not a safe assumption any hospital will, just be hopeful and optimistic they’ll reduce the cost on you because those bills are simply too high on top of other bills. Do not presume you don’t have a snowball’s chance in hell just because you may not have the upper hand with the costs, or knowledge. Be in control.  

For just an idea of the insurance benefit, within the first year of surgeries and all treatments and tests, and prescriptions and office visits, my total bill was approximately $200,000. Come tax time, we requested a detail of the whole kitnkaboodle to try to meet the medical deduction. Nope. Didn’t have high enough expense to justify. That sucked. And it would really suck to accumulate so much medical debt to rate that deduction the goddamn IRS says is fair. How the hell would the typical couple pay their bills?? How can the average woman with a house and car payment and kids to feed handle all that debt of hospital costs to make those deductions? I say it’s BULL.

The cold reality of healthcare business is everyone has a job to do regardless of how a patient copes with the emotional aspects, how the bills get paid, how the laws apply to ensure her reconstructive recovery. One of my doctors implied just how governmental regulations impede proper treatment for thousands of breast cancer patients. I believe that fact is a contributor, dare I say obstructs, at least a percent of women from receiving the best care for proper healing from breast cancer, a mastectomy and reconstruction. The whole cure.

Thankfully my husband dealt with all of those matters so my primary concern was getting well. I had difficulty concentrating or discussing the politics of those bills with the billing reps. I’m grateful KU worked with my husband to keep our credit in good standing.

I am not a financial wizard; you should not need a lawyer to assure you get the proper treatment which is your right by law.

Links by state:

State Laws on Breast Reconstruction


 

 

 

[1] “Paying for Reconstruction Procedures – Breastcancer.org.” 2014. 7 Mar. 2016 <http://www.breastcancer.org/treatment/surgery/reconstruction/paying-for>