Questions To Ask About Paying for Mastectomy or Lumpectomy
Mastectomy and lumpectomy are usually covered if you have health insurance, but you can still end up owing more than you might think. According to a 2022 Breastcancer.org survey of 1,437 people who were diagnosed with breast cancer, 32% of them had unexpectedly high out-of-pocket costs for their surgery.
Some people have high co-payments and co-insurance rates for a mastectomy or lumpectomy, while others face high costs because their breast surgeon or plastic surgeon is outside their health plan’s network. Some health plans also have provider tiers, even for in-network doctors: depending on which tier your surgeon is in, you may have higher or lower out-of-pocket costs.
It’s helpful to talk with your breast surgeon, your health insurance company, and a financial navigator about ways of minimizing your out-of-pocket costs and getting as much of your surgical care covered by health insurance as possible. If you don’t have health insurance, a financial navigator can help you look at different options and apply for coverage.
Don’t wait for your healthcare team to bring up cost and coverage issues. It’s a good idea to be proactive and make sure you get your questions answered. And since it can be overwhelming to handle payment and insurance issues on top of everything else, consider asking a friend or family member to join you for these conversations.
Questions to ask your breast surgeon
When you are looking for a breast surgeon, it’s possible some staff might be more helpful and responsive to financial questions than others — and it may help you decide which surgeon to work with.
Keep in mind that in certain cases, especially if you are getting a prophylactic mastectomy, you and your doctor may need to work together to convince the health insurance company to cover it and provide documentation of why the surgery is medically necessary. No federal laws require health insurance companies to cover prophylactic mastectomy, but some state laws do. Here are some questions to ask your breast surgeon:
Do you accept my health insurance plan and are you considered in-network?
Can you work with me on getting prior authorization (also known as pre-approval or pre-certification) for my surgery and any related tests or treatments from my health insurance company? How does that process work?
What are some of the ways you could help me appeal any denials of coverage, if necessary?
Is there a plastic surgeon you can add to my cancer care team (at the same hospital) who accepts my insurance and who could perform my immediate reconstruction?
How many days should I expect to take off from work for the surgery and recovery (and any follow-up care)? What kinds of help might I need from a caregiver? What limitations should I plan for during my recovery (for example, not being able to drive or having limited mobility)?
Are there any appointments related to my surgery or follow-up care that can be switched to video visits or phone visits (so I don’t have to take off from work or spend time travelling back and forth)?
If I’m worried about the cost for my surgery and about my health insurance coverage (or lack of coverage), who else besides you can help me? Can you refer me to a financial navigator? Can I negotiate a lower price for my surgery or a no-interest payment plan with your practice or with the hospital?
Questions to ask your health insurance company
It’s important to speak with a representative from your health insurance company so you can have a better understanding of what’s covered, your out-of-pocket costs, and the rules for how to use your benefits.
When you speak with someone at the health insurance company, be sure to take detailed notes on each call: write down the date, what you discussed, the name of the person you spoke with, and a call reference number (which you may have to ask for). It can be tricky to get clear answers or to resolve issues that come up with your coverage: keeping good records of your communication can help.
It’s important to know that according to The Women’s Health and Cancer Rights Act, a federal law, most group health plans that cover mastectomy must also cover breast reconstruction. Medicare covers breast reconstruction, while Medicaid coverage can vary from state to state.
Read more about paying for reconstruction procedures.
Here are some questions to ask your health insurance company:
Does my plan cover the surgery or surgeries I want to have? (It’s helpful to have the procedure code, or CPT code, for the surgery when you ask this question. You can get that from your breast surgeon’s office.)
Are the surgeons I want to work with in-network for my health plan?
Am I limited to in-network surgeons and services? If my plan covers out-of-network care, how does that coverage work?
How do I apply for an out-of-network exception (also known as a network gap exception)? (This is a good question to ask if you want to work with a surgeon who is out-of-network and your plan doesn’t cover out-of-network care.)
How does my plan’s coverage for second opinions work? Is there a limit on the number of consultations that can be covered? Do the appointments have to be in-person rather than virtual? Do I need to get referrals for the appointments to be covered? What if I want to have a consultation with a surgeon who is out-of-network?
Do I need to get prior authorization for my surgery?
Does my plan cover a hospital stay? If so, for how many days?
What out-of-pocket costs related to my surgery (such as my deductible, co-payments, or co-insurance percentage) am I responsible for?
What is my annual out-of-pocket maximum (the limit on what you have to pay for covered, in-network healthcare services for the year, not including monthly premiums)?
On which date do my deductible and out-of-pocket maximum reset (return to zero)?
What is the time limit for submitting health insurance claims?
How do I appeal the decision if you deny coverage for my surgery? What is the time limit for submitting appeals?
Are all payments made directly to the healthcare providers involved in my surgery?
The hospital or cancer center where you’re having your mastectomy or lumpectomy may have a financial navigator or oncology social worker who can help you manage costs. Another option is to work with a national non-profit organization that offers free financial navigation, such as Triage Cancer or the Patient Advocate Foundation. Here are some questions to ask a financial navigator:
Can you help me get health insurance coverage for my upcoming surgery? (This is a good question to ask if you don’t have health insurance or your health insurance isn’t adequate for your needs.)
Am I eligible for financial assistance from the hospital, cancer center, or surgical practice where I’m receiving my care? Can you help me apply for that financial assistance?
If I need to take time off from my job for the surgery and recovery, what are my legal rights, which kinds of paid or unpaid leave am I eligible for, and can I access disability insurance benefits if needed?
Can you connect me with any other resources or programs that could lower my out-of-pocket costs for my cancer care?
Learn more about Covering the Costs of Your Breast Cancer Care and read our Special Report on the Cost of Breast Cancer Care.
— Last updated on August 17, 2024 at 1:36 PM