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Insurance & Nose Surgery

Many patients considering nose surgery often wonder whether or not their health insurance covers this type of surgery. And if their health insurance does cover nose surgery, the question is whether or not it will cover the type of surgery that they are interested in having done. Unfortunately, this can be a very confusing topic for patients and plastic surgeons alike. Hopefully in this online tutorial chapter I can help shed some much needed light on the topic of health insurance as it relates to nose surgery including rhinoplasty and revision rhinoplasty.

What Type Of Health Insurance Do You Have?

The first thing you have to clarify is what type of health insurance do you have? There are basically two different types of health insurance.

The first is called an HMO, which stands for health maintenance organization. This is the type of health plan where you pay a monthly ‘premium’ (your monthly payment) to see doctors that belong to the HMO group. These doctors have an agreement with the HMO to see patients having this type of HMO coverage. You, in turn, agree to only see doctors that have this agreement with the HMO. A major issue with HMO health care plans is that you have to have your health care orchestrated through a primary care provider, or PCP. So if you have a deviated septum or fracture your nose, you must see your PCP before being ‘referred’ to a specialist. And the specialist you would see, for instance, the rhinoplasty specialist, would be a surgeon within the HMO plan. If you happen to like a different rhinoplasty specialist who does not belong to the HMO (also phrased as being ‘outside’ of the HMO), you are, unfortunately, out of luck. In very rare cases, your HMO may grant permission to be treated by a surgeon outside of the HMO plan, but this is definitely the exception rather than the rule. So in a sense, you are stuck with seeking treatment by the surgeons that are listed in your HMO.

The second major type of health insurance is a PPO plan, or preferred provider plan. In a PPO health care plan, you pay a monthly premium to have your health care covered like in an HMO. The difference is that in a PPO health care plan, you do not have to go through a PCP in order to seek care with a specialist. So you do not need the PCP ‘referral’ that is so often a source of frustration in an HMO plan. You are free to seek out any physician that takes your PPO insurance to have care and treatment administered. Nowadays most surgeons take most PPO health care plans. Meaning, these surgeons have an agreement, or contract, with the PPO to treat their patients. These surgeons are labeled as being ‘in network’ since they belong to the network of doctors that have the agreement with the PPO. There are, however, some surgeons who are not contracted with these particular PPO plans. These surgeons are considered ‘out of network’ since they do not have any formal agreements with the PPO. When it comes to health care coverage, you will be covered more (meaning pay less) by having your care with a network PPO physician. If you go out of network, you will still have some degree of health care coverage. But you will pay more out of pocket to see the out of network versus the in network surgeon. So make sure you clarify in advance of your visit whether or not your chosen surgeon is in network with the PPO plan. This could translate into a significant cost savings for you and your family when it comes to nasal surgery.

Now there are a variety of other health insurance plans that fall somewhere in between an HMO and PPO plan, but I could not do it justice to try and explain all of the nuances here. The major differences are really between HMOs and PPOs. Keep in mind that it is ultimately the patient’s responsibility to understand their own health insurance coverage. So read your policy very carefully and if you have any questions, make sure you contact your health plan representative directly.

Of note, I personally do not belong to any HMOs. But I am in network with a number of PPOs when it comes to treating patients who require nasal reconstructive surgery.

Deductibles, Co-Insurance, Out of Pocket Max & Copays

Most of the information below relates to PPO insurance plans.

A deductible is a term that refers to a threshold amount of money that a patient has to pay out of pocket before their health insurance policy kicks in. For instance, if you have a deductible of $1500 for a planned septoplasty surgery, you will be responsible for paying the $1500 before your insurance plan actually kicks in. Most deductibles are considered annual deductibles and reset each calendar year. This is often times why many patients seek to have additional surgery towards the end of the year if their deductible has already been met for that year. If they wait until January of the following year, the deductible resets and they must meet this amount once again before insurance kicks in again. Usually the higher the deductible, the lower your monthly premiums are in a similar fashion as automobile insurance. Now keep in mind that some insurance plans have different deductibles for different types of service being provided. For example, they might have a $2000 deductible for surgical services like septoplasty, but a $500 deductible for pharmacy prescription coverage.

A second term commonly used in the industry is co-insurance. Co-insurance refers to the amount of money, based on a percentage (not a fixed amount), that you are responsible for paying for each medical bill submitted by your surgeon. For example, a common co-insurance is what they call ’80/20′ where the insurance company pays 80% of the medical bill and the patient pays 20% of the amount. Co-insurance applies to medical bills that are above and beyond your deductible amount and simply outlines how the patient and insurance company will share the bills up to the out of pocket maximum.

The out of pocket maximum, or cap, is a certain dollar amount that you have to pay before your insurance plan begins to pay 100% of your medical bills. Expenses that can be applied to your out of pocket max each year include your deductible and co-insurance that may have been paid. Usually, copays (see below) and monthly premiums do not apply to the out of pocket max.

Copay refers to a fixed amount of money that is paid by the patient every time they seek care or services. For example, if your PPO plan has a $30 copay, you are responsible for paying this amount of money every visit to the doctor irregardless of whether or not you have met your deductible and/or co-insurance.

Types of Nose Surgery Covered By Health Insurance

Now that we have reviewed some of the financial terms used in the insurance industry, we can begin to focus on the types of nose surgery that are covered by health insurance.

In general, health insurance typically will provide coverage for medical conditions that adversely impact nasal function and cannot be readily treated with medication. The most common problems that fit this description include a deviated nasal septum, enlarged or overactive turbinates, nasal valve stenosis (or narrowing), and nasal fractures (broken nose). However, just because you are diagnosed with one or several of these conditions does not necessarily mean that you are automatically eligible to have surgery paid for by your insurance. You must first consult with a surgical specialist in this area – usually this is a board certified otolaryngologist (also known as an ENT or head and neck surgeon) or facial plastic surgeon. I happen to be board certified in both surgical subspecialties, which makes me uniquely qualified to evaluate and treat these type of conditions related to the nose. Once a qualified surgical specialist makes the diagnosis, they will then recommend a surgical treatment plan for your particular case.

Deviated Septum Surgery (Septoplasty or Septal Reconstruction)

Surgery for a deviated septum is called a septoplasty, or septal reconstruction. This surgery involves straightening the septum to address breathing problems that arise from a crooked septum. A deviated septum is something that many patients are born with and elect to have repaired as an adult because of breathing problems. Others develop a deviated septum as a result of some injury to the nose. Keep in mind that traditional septoplasty, or septum surgery, will not change the cosmetic appearance of the nose. Just because you have been diagnosed with a deviated septum and told that septoplasty surgery is needed, does not mean that your insurance will pay for you to also have a nose job done. Many patients do elect to have their nose reshaped at the same time as having septal surgery, but one can be done without the other.

To learn more about septoplasty surgery please reference our online rhinoplasty tutorial on septal reconstruction.

Enlarged Turbinate Reduction Surgery

The turbinates are normal structures inside the nose that run parallel to the nasal septum and help your nose humidify inspired air. There are actually three pairs of turbinates in the nose – the inferior, middle and superior. In most cases of nasal obstruction, it is the inferior turbinate that is the culprit. In many patients, the turbinates become enlarged, which can block the nasal airway in terms of breathing. When they do so, they can also become overactive and contribute to more nasal congestion. Topical medications, such as nasal steroid or antihistamine sprays, are the first line of treatment for this condition. If the medications do not work effectively or there are side effects from the sprays (such as nose bleeds and irritation), turbinate reduction surgery might be warranted. The turbinate reduction surgery is intended to make the turbinate structurally smaller while also reducing the activity of the turbinate so that there is less nasal congestion. This is done using one of several different techniques available out there. The most frequently used in my practice include partial resection, or removal, of the turbinate as well as cauterization of the turbinate. In a significant number of patients, enlarged turbinates can be found in conjunction with a deviated septum. When this situation occurs, these patients typically require combined turbinate reduction surgery along with septoplasty.

Nasal Valve Stenosis Surgery

Nasal valve stenosis implies a very specific condition where the nose is blocked on the inside due to narrowing of either the external or internal valve. These two critical areas inside of the nose refer to the nostril opening and the middle one-third of the nose on the inside, respectively. Surgery for external nasal valve narrowing usually involves placement of what is called a ‘batten graft,’ whereas surgery for internal valve narrowing is referred to as ‘spreader graft’ placement. Both types of nasal valve surgery are intended to help open the nose up internally to improve one’s nasal function (breathing). Your chosen rhinoplasty specialist should be able to determine whether or not you are a candidate to have this type of nasal reconstruction based on a detailed physical examination of your nose. Although nasal valve surgery is primarily intended to help improve your nasal function, in most cases there is some passive change in the appearance of the nose as a result of placement of these grafts.

Repair Of A Fractured (Broken) Nose

Repair of a fractured, or broken, nose is a very common procedure that is usually covered by your health insurance. In most cases, patients who have fractured their nose elect to have it repaired within the first two weeks of sustaining the injury. Others choose to wait months to years later before having the broken nose fixed. In a majority of patients who have a fractured or broken nose, there is some degree of visible change to the appearance of the nose. For instance, the nose can look crooked or shifted over in terms of alignment. Or the nose can appear collapsed as a result of the injury. In addition to a change in the appearance of the nose, a fracture can also cause difficulty breathing. This commonly results from a traumatic injury to the septum at the same time. The septum, which may be have been relatively straight before the injury, can be fractured and shifted over as well. This can cause a deviated septum that contributes to obstruction of the nasal passage. In this type of injury to the nose, the septum should be addressed at the same time as the fractured nose is being repaired.

Getting Insurance To Cover Your Nose Surgery

Once your nose specialist has properly diagnosed you with a certain condition that warrants surgery, they typically need to communicate this information to your health insurance carrier. Most nose specialists will write up a letter summarizing their findings and recommendations.

Every diagnosis (for example, deviated nasal septum) has what is called an ICD code. In the medical insurance industry, these ICD codes correspond to a specific diagnosis. For a deviated septum, for instance, this is 802.0. If you have more than one diagnosis, an ICD code has to be submitted for each one.

Every procedure (for example, septoplasty) has what is called a CPT code. In medical industry jargon, a CPT code corresponds to a specific procedure that is being performed. For instance, the CPT code for a septoplasty, or septal reconstruction, is 30520. Like the diagnoses codes, each proposed procedure requires a specific CPT code. The CPT codes are of more interest to the health insurance company since these codes determine what is being paid out to the surgeon, anesthesiologist and surgery center.

The ICD and CPT codes are sent to your insurance company for what is called preauthorization. The preauthorization process is a requirement of your insurance company before you have surgery. It is sort of like them giving permission to your surgeon to perform the procedures that are being recommended. I say sort of because, unfortunately, the preauthorization process is not a guarantee that all the procedures will indeed be covered by your insurance carrier. Now not all surgical procedures require preauthorization, but it is always a good idea to submit all the codes being performed so your insurance company is well informed of what is going on with your care. A denial of coverage means that your insurance company is denying you coverage to have that particular procedure or combination of procedures performed. Fortunately, you have an option to appeal this decision if there is a denial.

Explanation of Benefits (EOB)

Once your surgery has been completed, your surgeon, anesthesiologist and surgery center (also known as the facility fee) will submit bills to your insurance company for payment. After processing these, your insurance company will make payment individually to the surgeon, anesthesiologist and facility. A copy of this payment will be sent to you as well in what is called an explanation of benefits, or EOB. This usually outlines what was billed to your insurance company, what your insurance is going to pay out, and your financial responsibility.

In most cases, patients are quite surprised at how high the fees are for the surgeon, anesthesiologist and facility. But before you get too excited, these dollar amounts are hardly ever paid out to the respective parties involved. In fact, the surgeon, anesthesiologist and facility are typically paid only a fraction of the fees that were requested. Rarely are payments anywhere near what was billed to your insurance company.

What About Cosmetic Nose Reshaping Done At The Same Time?

There are quite a number of patients who choose to have cosmetic reshaping of the nose, or cosmetic rhinoplasty, at the same time as functional nose surgery. There is an advantage in doing so since you will already be under an anesthetic and you can combine the healing process into one recovery period. But it is real important to understand that any reshaping of the nose done for strictly cosmetic reasons will not be covered by your health insurance. And despite paying for the cosmetic rhinoplasty portion, you will still be financially responsible for any and all deductibles, co-insurance, and copays that arise from the functional nose surgery. Meaning, any out of pocket money you pay for the cosmetic rhinoplasty cannot be applied to any of the fees that are due from your insurance company.

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