insurance

What is the role of Insurance in Plastic Surgery?

Cosmetic procedures are typically not covered by your insurance. There are some plastic surgery procedures, however, that could potentially be completely covered by your insurance. These procedures are typically medically necessary procedures that restore and bring back a lost function or alleviate certain functional impairments. Some examples include but are not limited to large breasts that cause significant back pain as well excessive skin around your abdomen after massive weight loss.

Dr. Papafragkou at Plastic Surgery Associates of Long Island is a triple board-certified Plastic Surgeon who is out-of-network but works on a daily basis with most of those insurance companies to get coverage for his patients. Dr. Papafragkou has been performing these procedures for over 10 years now and has the skills and expertise to deliver the best possible outcome.

What Plastic Surgery Procedures could potentially be covered by insurance?

The following Plastic Surgery procedures can be covered partially or completely by insurance:

• Breast Reduction/lift
• Breast Implant exchange with removal of capsular contraction.
• Breast cancer reconstruction.
• Fat grafting to the breast with or without implants placement after breast reconstruction.
• Removal of excess skin after massive weight loss.
• Removal of excess skin and fat around the abdomen, panniculectomy.
• Scar Revisions anywhere in the body.
• Combination of Breast reduction and panniculectomy in some patients.
• Correction of male large breasts, gynecomastia correction.

What insurance companies do we work with?

• NYSHIP
• Cigna
• Blue Cross/Blue Shield
• Oxford
• Emblem
• Aetna
• United Healthcare

And many others. Contact us to find out if you qualify.

What insurance do we NOT accept?

We do not accept Medicare and Medicaid. 

Does my insurance have out-of-network coverage?

A lot of insurance policies typically offer both in-network and out-of-network coverage. Every plan is different. You can easily find out by contacting a representative by calling the phone number at the back of your insurance card. 

Do I need to have out-of-network benefits to qualify?

Not necessarily. Sometimes a medically necessary procedure can be approved even if you don’t have out-of-network benefits. Contact us to inquire.

How does the whole process work?

We will request your insurance information before your arrival at the office or at the time of your appointment. At the initial consultation Dr. Papafragkou will examine you and determine if you are eligible for the procedure, you are looking for. Pictures will be obtained for your insurance company. Please bring any supporting documents with you during the visit. For example, if you suffer from back pain due to large breasts please bring with you any documentation you may have from physical therapy, chiropractor’s notes or your primary care doctor. Some insurance plans want to make sure all conservative measures have failed before authorizing surgery.

Immediately following your initial visit, a pre-authorization request will be filled with your insurance company. Most insurance companies will want to review all the medical information provided including any imaging studies and/or supporting documentation before pre-approving/Pre-authorizing a surgical procedure.

Please note that a pre-approval is not guarantee of payment but helps us submit a claim after your procedure. In addition to this the hospital where the procedure will be performed will require us to see a pre-authorization before they allow us to schedule the surgery.

In some rare cases pre-approval may not be required from your insurance company. If that happens then we apply for a pre-determination to make sure that your insurance company agrees with the medical necessity of your case.  This again is not a guarantee of payment but helps us with the claim afterwards. If pre-determination is not allowed by your insurance company, then your potential financial responsibility will be discussed on an individual basis.

We will bill your insurance plan after the procedure is done. Dr. Papafragkou and his team are out of network. Each insurance policy is unique with different deductibles, co-insurance and potential plan exclusions. Each case is evaluated on individually basis.

How long is the whole process?

The whole process after your office visit will take about 6-8 weeks. Most of the time it is much sooner. Our initial pre-authorization may be accepted or denied or more supporting documentation maybe needed. If denied, we proceed to a first and second level appeal if necessary. Dr. Papafragkou will do the best he can to get application approved including a potential peer-to-peer review. Some cases may take longer to process as each insurance plan is different. Rest assured that we will try to coverage approved in a timely manner.