Insurance and breast reconstruction: your rights, and how Altris works

Navigating insurance during breast reconstruction is stressful. Here is what you need to know about your rights, how Altris works, and how to make the most of your coverage.

Is breast reconstruction covered by insurance?

Yes. The Women's Health and Cancer Rights Act (WHCRA) of 1998 is a federal law that requires any group or individual health plan covering mastectomy to also cover:

• All stages of reconstruction of the breast on which the mastectomy was performed
• Surgery and reconstruction of the other breast to achieve symmetry
• Prostheses and treatment of physical complications, including lymphedema

WHCRA covers both implant-based and natural tissue (autologous) reconstruction. Coverage decisions must be made in consultation with your surgeon, not unilaterally by your insurer.

Is Altris in-network with my insurance?

Altris is a fee-for-service, out-of-network practice. We do not participate in any insurance networks.

This is a deliberate choice. It allows us to spend the time each case requires, in consultation, in planning, and in the operating room, without the constraints that come with insurance contracts. For complex reconstruction and revision surgery, that time is not a luxury. It is the difference between a good outcome and a great one.

Does that mean insurance will not help cover my costs?

Not necessarily. Being out-of-network does not mean you are on your own.

Here is how it works:

• Facility and anesthesia costs are typically covered directly by your insurance under WHCRA, regardless of whether your surgeon is in-network.
• The surgeon's fee is your direct responsibility, but if your plan has out-of-network benefits, you can submit this fee to your insurance company for reimbursement. Most plans with out-of-network benefits will reimburse a portion, after your deductible and coinsurance apply.
• We will work with you to obtain pre-authorization for your procedure and provide all documentation needed to submit a claim.
• Upon request, we provide a superbill, an itemized receipt with all the procedure and diagnosis codes your insurer needs to process a claim. You submit this directly to your insurance, and any reimbursement they approve comes back to you.

If your plan has out-of-network benefits, we encourage you to submit all charges to your insurance. You may receive more reimbursement than you expect.

What should I ask my insurance company?

Before your consultation, call the member services number on the back of your insurance card and ask:

1. Do I have out-of-network benefits?
2. What is my out-of-network deductible, and how much have I met this year?
3. What is my out-of-network coinsurance percentage?
4. Is there an out-of-network out-of-pocket maximum?
5. Does my plan cover breast reconstruction under the Women's Health and Cancer Rights Act?
6. What documentation do I need to submit a claim for an out-of-network surgeon's fee?

Write down the answers, the date of the call, and the name of the representative. This protects you if there is a dispute later.

What about secondary reconstruction, revision, or adjunctive procedures?

Procedures such as fat grafting, nipple reconstruction, symmetry procedures, revision surgery, and correction of implant complications may not be covered under WHCRA depending on your plan and the nature of the procedure. Some insurers categorize these as cosmetic.

That said, we recommend submitting all charges to your insurance if you have out-of-network benefits. Coverage decisions vary by plan, and some patients receive partial or full reimbursement for procedures their insurer initially categorizes as elective. We provide detailed documentation to support your claim.

What is the No Surprises Act, and does it apply here?

The No Surprises Act is a federal law that took effect in 2022. It is designed to protect patients from unexpected medical bills in specific circumstances, primarily when a patient receives care from an out-of-network provider at an in-network facility without prior knowledge or consent. It also requires healthcare providers to give uninsured or self-pay patients a written estimate of costs before scheduled care.

At Altris, we are transparent about our fees from the outset. Before you schedule surgery, you will know what your costs will be. There are no surprise bills.

How do I get started?

The best first step is a consultation. We will discuss your goals, your surgical options, and your anticipated costs, and we will help you understand what to expect from your insurance before you make any decisions.