Waiting for Authorization for Breast Reconstruction

It can take enormous patience for breast cancer patients who are waiting for authorization for their breast reconstruction procedure. I was once there. Now I am an advocate for all options of breast reconstruction after mastectomy. I interact with patients daily. Many times, their questions are a catalyst for topics to write a blog. Amplifying our voices to educate is part of patient advocacy responsibility.

I recently received an email from a patient who was denied coverage for a revision phase of her reconstruction. Her plastic surgeon even wrote an appeal, but it was still denied. She reached out to me for help and suggestions about what to do.

I take a deep breath when I get these emails and step out of my breast cancer survivor role and put on my patient advocate hat. I don’t want to offer false hope, but I sense the sadness, frustration, and fatigue from patients in these emails I frequently receive. Insurance, in any medical circumstance, is becoming a challenge for physicians and patients alike. I read this article recently and I think it’s time to address this topic in relationship to breast reconstruction.

What About That Law?

You decide to move forward with breast reconstruction after mastectomy. You research and decide on a plastic surgeon. It may require that you travel out of town or out of state for breast reconstruction. At the top of your list should be a call to the plastic surgeon’s office to see if they take your insurance.

But wait! Wasn’t there a law passed in 1998, the WHCRA, Women’s Health and Cancer Rights Act? Why yes! That law was passed and here is what it states from the Department of Labor.

If you have had a mastectomy or expect to have one, you may be entitled to special rights under the Women’s Health and Cancer Rights Act of 1998 (WHCRA)

Awesome, right? And you can even go to the American Cancer Society’s page and find similar information. Here is what they say.

The federal law requires most group insurance plans that cover mastectomies to also cover breast reconstruction. It was signed into law on October 21, 1998. The United States Departments of Labor and Health and Human Services oversee this law.

May and Most: The Devil’s in the Details!

Look carefully in these quotes and the words, “may” and “most”? There are nuances to insurance coverage that breast cancer patients must tackle head on in the middle of an already trying time after a diagnosis. It can be exhausting and emotional for the strongest and most educated of patients. Those that are not savvy or do not have the wherewithal to wade through the maze of these nuances are left feeling tired and hopeless.

Let me point out one such example of a nuance. There is something called “self-funded” plans in insurance. This can be a logistic headache for a provider, i.e., your plastic surgeon’s office, as well as you, the patient. Self-funded programs are those that can possibly deny breast reconstruction coverage as described here from the Centers for Medicare and Medicaid Services website:

Sponsors of self-funded, non-Federal, governmental plans may elect to exempt those plans (“opt out”) from the following provisions of title XXVII of the Public Health Service (PHS) Act:

3. Required coverage for reconstructive surgery following mastectomies (Women’s Health and Cancer Rights Act of 1998);

The Patient Patient

How does that leave the patient feeling waiting for authorization for breast reconstruction?

• Tired?
• Emotional?
• Hopeless?
• Anxious?
• Frustrated?

Consider the plastic surgeon’s office whose job it is to engage with insurance companies and help the patient abate those emotions. What complications do they face while waiting for authorization for a patient’s breast reconstruction?

• Multiple phone calls.
• Mountains of administrative paperwork.
• Maintaining professional balance between the patient and insurance provider for the benefit of the patient’s care.

Advice While Waiting for Authorization for Breast Reconstruction

• Always provide full disclosure of all your medical information to your plastic surgeon. Sometimes the smallest piece of information you unintentionally forgot can be the missing piece of the puzzle in authorizing your procedure.
• Step away from the phone when you feel frustrated. Reconstruction, although timely in many aspects, is seldom an emergency medical situation. Take a day off, do something unrelated to your diagnosis and plans for reconstruction. Revisit the process in a day or two.
• Be that “patient patient” when you are speaking with your plastic surgeon’s office. Try speaking to your feelings rather than taking out your frustrations to the human voice on the other end of the line. Say something like, “This diagnosis has been so hard for me and I’m really counting on your help right now. I appreciate you doing everything you can to assist me.” We can all use a bit of polite patience in this process.
• Find support from family or other women who have been through the process. They are on the other side and may offer a clearer approach when you’re feeling exhausted and frustrated.

It takes persistence and fortitude during this emotional journey through a diagnosis. What have you done to ease the burden of waiting for authorization for your breast reconstruction? I’d love to hear your feedback.

 

Disclaimer

References made to my surgical group, surgeon and healthcare team are made because they are aligned with my values and met my criterion after I did research of their practices and success rates. Any other healthcare provider that displays the same skill, compassion education and outreach to patients will be given consideration and recognition on this website.  The information contained on this website is not a substitute for or should be construed as medical advice. Please consult a licensed physician for medical advice.