Breast Reconstruction: Why Going Out-of-Network Might Work for You

By Andrea Smith

A diagnosis of breast cancer turns a woman’s life upside down. Despite roiling emotions, she must make crucial decisions about treatment and figure out how to manage her life in the face of a new reality. Not least among her concerns are the financial ramifications of her illness, particularly if she will need a mastectomy. Will her insurance cover reconstruction? The surgeon, the anesthesiologist, the hospital, the lab? Procedures on the healthy breast to ensure symmetry? What if she elects to have reconstruction at a later date? What if her preferred surgeon is not in her insurer’s network? I have worked with multiple in-network and out-of-network plastic surgeons in the past and I.m currently Practice Manager for Breast Reconstruction Specialist Dr. Constance M. Chen. I believe that the most important information is that all insurance policies will cover – in fact, must cover – breast reconstruction if it covers mastectomy.

In 1998, Congress passed the Women’s Health and Cancer Rights Act (WHCRA), a federal law that requires group health plans and individual health policies that cover mastectomy to also cover breast reconstruction in connection with such mastectomy. Before the passage of the WHCRA, insurers could refuse coverage for reconstruction on the grounds that these were cosmetic procedures and not medically necessary. Women had to pay for reconstruction themselves or forgo it. Supporters of the WHCRA recognized that ensuring that a woman has the option of reconstructive surgery following mastectomy is important to her physical and emotional well-being.

But even with the protection of the law there is no escaping the anxiety and uncertainty that accompany decisions about breast reconstruction – anxiety that is compounded by the difficulty of navigating the rules and regulations that govern insurance coverage and claims. A critical decision at this time is the woman’s choice of surgeon. She must choose a doctor who offers a full range of reconstructive options, including the most advanced techniques, but she must also feel comfortable that her medical team understands her unique concerns and preferences and understands how to work with her insurer to ensure that she receives all the benefits to which she is entitled.

Given the importance of this decision, whether or not the doctor is in her insurer’s network is an important concern – but it is one that a woman may be able to overcome. Out-of-network” simply means that a doctor does not have a pre-negotiated contract with a given health insurance program or company. “In-network” providers have contracted with insurers to provide services to plan members at pre-negotiated rates. Patients have been conditioned to avoid out-of-network providers for fear that their costs will be higher. But that will not always be the case and often an out-of-network surgeon will be exactly the right choice for breast reconstruction.

There are many reasons a woman may choose an out-of-network provider for breast reconstruction: She may have researched restorative options, decided on a particular one, and found that in-network providers either do not offer the procedure or do not have the experience and expertise to instill confidence. Or her research might have pointed her to a particular doctor who has developed or perfected an advanced technique. She may have a compelling recommendation from a family member, a friend, or a trusted medical source. Or she may have met with in-network providers and felt that they were not right for her for any number of reasons.

The most important criterion in choosing a surgeon is the patient’s confidence and comfort level. This is relevant not just for the surgery itself but to ensure that her care will not impose an undue financial burden. The surgeon’s team must work with the patient to help her understand – in advance – her insurer’s requirements, to accurately estimate her expected out-of-pocket costs, and to minimize the risk of unexpected costs.

In our practice, the surgeon focuses exclusively on the clinical aspect of the patient’s condition and treats every person without considering her insurance status. My job is to make sure that every patient who wants to go out of network has full access to our services. We want women to be able to focus their energies on getting well. We have many years of experience working with insurers and we do everything we can to relieve our patient of the anxiety and stress of managing the financial aspects of her care.

Andrea Smith is the Practice Manager for Constance M Chen, MD, PC, a boutique plastic and reconstructive surgery office located in New York City that focuses on innovative natural techniques to optimize medical and aesthetic outcomes for women undergoing breast reconstruction. The practice is committed to patient advocacy and a woman’s right to choose her own breast reconstruction journey.  www.constancechenmd.com