More Than Half of Plastic Surgeons Surveyed Report Insurance Coverage Denial for Patients with Childhood Deformities, Disfigurement and Congenital Defects
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Arlington Heights, Ill. (December 10, 1997) -- John Grisham's The Rainmaker is a story about an insurance company that routinely denies coverage for medically necessary procedures. Unfortunately, this scenario doesn't just occur in books and movies. In a recent survey conducted by the American Society of Plastic and Reconstructive Surgeons (ASPRS), more than half of plastic surgeons polled reported insurance denial or trouble obtaining coverage of procedures for deformities, disfigurements and congenital defects in children.
"I struggle personally every day with denial for reimbursement for these deformities, and while the results of the poll are alarming, they are not surprising," says Dennis Lynch, MD, president of ASPRS.
"Insurance coverage denial for pediatric plastic surgery procedures is a symptom of the broader issues plaguing the state of medical care in this country today," says Dr. Lynch. "From decreased hospital stays to an increased number of insurance denials for procedures traditionally covered, insurance companies rather than medical professionals are determining the quality of patient care."
"Who should be determining what is 'medically necessary,' -- insurance companies or physicians?" adds Dr. Lynch.
ASPRS is dedicated to alerting the public to this issue and educating insurance companies about what constitutes reconstructive versus cosmetic surgery. In addition, ASPRS will work with other patient and physician organizations to pass legislation to ensure coverage for childhood deformities, disfigurements and congenital defects.
The American Medical Association showed its support of ASPRS' endeavors by passing a resolution today on this issue. When the AMA passes a resolution, it officially goes on record in support of an issue, in this case insurance coverage for procedures associated with childhood deformities, disfigurements and congenital defects.
ASPRS found the most often denied childhood deformities, disfigurements and congenital defects procedures are associated with: 1) nose reshaping for congenital nasal deformities related to cleft lip and craniofacial deformity; 2) repair of abnormally small outer ear (microtia); 3) cleft lip repair.
Kenneth Salyer, MD, of Dallas, a specialist in pediatric plastic surgery, has witnessed many times the additional anguish caused to families by denied insurance coverage. "It is an outrage that families must also have to worry about obtaining insurance coverage for medically necessary procedures during this already stressful time in their lives. Battling with insurance companies for coverage only adds to the tragedy of their situation."
Most often cited reasons given by insurance companies for denial are: the procedure is not medically necessary; is cosmetic in nature; or is not needed for functional purposes.
The American Medical Association defines cosmetic and reconstructive surgery as follows, and encourages third-party payers to use these definitions in determining eligible services for coverage under the plans they offer or administer:
Cosmetic surgery is performed to reshape normal structures of the body in order to improve the patient's appearance and self-esteem.
Reconstructive surgery is performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease. It is generally performed to improve function, but may also be done to approximate a normal appearance.
"ASPRS is committed to this issue and views it as one of its main initiatives for 1998, and beyond as necessary," says Dr. Lynch. "We want to ensure that parents can focus on caring for their child, not hassling with insurance companies for coverage they rightfully deserve."
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The American Society of Plastic and Reconstructive Surgeons represents 97 percent of all physicians certified by the American Board of Plastic Surgery (ABPS). By choosing an ASPRS member plastic surgeon who is certified by ABPS, patients are ensured that the physician has graduated from an accredited medical school and completed at least five years of additional residency, usually three years in general surgery and two years of plastic surgery. To be certified by ABPS, a physician must also practice plastic surgery for two years and pass comprehensive written and oral examinations. Consumers may call the Plastic Surgery Information Service at 1-800-635-0635 or access the ASPRS web site at www.plasticsurgery.org for informational brochures and names of qualified plastic surgeons in their areas.
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