Out-of-Network Insurance for Breast Reconstruction

Insurance and out-of-network care

What to expect financially when your reconstructive surgeon is out of network.

We are an out-of-network practice. That phrase worries people, usually because it sounds like a large bill waiting at the end. For most women having reconstructive surgery with us, it does not work that way.

Your reconstruction is covered

The Women's Health and Cancer Rights Act requires health plans that cover mastectomy to also cover breast reconstruction. That includes every stage of reconstruction, surgery on the other breast to achieve symmetry, prostheses, and treatment of complications such as lymphedema. It applies whether the mastectomy was for cancer or was risk-reducing, and it covers revision of a reconstruction that has already been done.

This surgery is a covered benefit, not an elective one you are asking your insurer to consider.

What you pay for surgery

We perform reconstructive operations within the Northwell Health system, whose hospitals participate in the networks of the vast majority of insurance plans in New York City. When an out-of-network surgeon operates at a hospital that is in your plan's network, federal law limits what you can be charged. Your copayment, coinsurance, and deductible are calculated at in-network rates and count toward your in-network deductible and annual out-of-pocket maximum.

In practical terms, you pay what you would have paid for an in-network surgeon performing the same operation at the same hospital. There is no further bill from us afterward.

If we and your insurer disagree about what the operation is worth, that is settled between the practice and the plan. You are not part of it, and it does not change what you owe.

Office visits and cosmetic surgery

Consultations work differently, because these protections apply to care given at a hospital rather than in an office. We charge a consultation fee and submit the visit to your insurer, and any reimbursement is paid directly to you. Purely cosmetic procedures are not covered by any plan, in or out of network, and are quoted in advance.

Before you decide anything

We verify your benefits and handle the insurance work, including authorizations and appeals, and we tell you where you stand before you commit to surgery.

Cost is not a rude question, and it is one we would rather answer before surgery than after it.

Call us at (917) 633-5750.

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