Insurance matters

healthinsuranceThe topic of insurance coverage has come up a bit in the Facebook groups recently. There were some good questions. Having been through a few (ha!) surgeries, appealing rejected claims, and recently switching from one provider to another (United Healthcare > Blue Cross Blue Shield), I have a little bit of experience dealing with insurance and can share some thoughts and things to consider.

Please note: I’m in the US and have coverage through my employer. Different insurance carriers and their plan benefits will vary, so call your provider with any specific questions you may have for your own scenario. Also, I am sharing my understanding based on personal experience; my costs outlined here. If you have additional tips, feedback, or corrections, please send them to me. Would love to get some information about Tricare too.

  1. Know your deductible, level of coverage/cost share, and out-of-pocket max (OOM)
    These amounts will tell you how much of the costs you will be responsible for. The deductible is how much you must pay up front before your insurance kicks in (ex: $1,000 for me); cost-share is the portion your insurance (or you, depending on how it’s written) will pay after deductible is met (ex: 80% covered by insurance/20% for me to pay) up to the OOM; the OOM is the maximum that you will have to pay out of your own pocket for the plan year ($3,500 for me). All of these amounts are in your plan documentation. Also, your plan will have different amounts for out-of-network providers, as well as individual vs. family amounts.
  2. Get pre-authorization for everything
    This is an important one. Typically the doctor’s office will handle this on your behalf, but may not. If you are responsible, do this for every single provider (and facility) that will be participating in your procedure. If your doc’s billing department is handling it, make sure you confirm with them. It is not unheard of for insurance providers to reject a claim because proper pre-authorization wasn’t granted .. even if it is a qualifying procedure and the provider is in-network. If rejected, appeal (see #4).
  3. Confirm a provider is in-network
    Another one that can get you. Don’t assume that because your plastic surgeon is in-network, that the anesthesiologist will be too. Different providers and facilities will bill separately and they may not all have a contract with your provider. For each of my surgeries I got a bill from plastic surgeon (+ onco surgeon for PBM), anesthesiologist, pathology lab, and hospital.
  4. Appeal any rejections
    If your insurance provider rejects a pre-auth request or claim, find out why. There are many possible answers: they deem a procedure medically unnecessary or experimental, procedure coding issue, no required pre-authorization, a provider or facility is out-of-network, etc. See if your doc’s billing department will help resolve. If not or unsuccessful, appeal. Call and find out what the appeal process entails. If it’s a medical necessity issue, ask your doc to write a letter. If it’s an out-of-network problem, explain why you used that doctor vs. another one in-network. You may have to attend a hearing or submit documentation.
  5. Check when your plan year resets
    Deductible and OOM typically reset when your plan year does and this doesn’t always coincide with the calendar year. This is important when you expect to have multiple procedures. Ex: if you’re having mastectomy and reconstruction with expanders and then implants, you will have two surgeries. Say your plan year starts in August and you have the mastectomy in April followed by exchange in October, you will have to pay OOM twice. I am now on my third plan year, unfortunately, so 3 x $3,500.
  6. Women’s Health and Cancer Rights Act (WHCRA, 1998)
    You may have heard of a law that requires insurance companies to pay for these procedures. This is it, but there are some caveats. First, the WHCRA does not require insurance companies to pay for a mastectomy. Your scenario will have to meet the provider’s criteria to be eligible for that coverage. However, if a mastectomy is covered, then reconstruction and any resulting complications must be covered. Also, you must still follow the rules as far as pre-authorization, cost sharing, and in/out-of-network providers are concerned. This law doesn’t extend to Medicare or Medicaid, but those have their own mastectomy-related benefits. Here are some additional points from the extremely helpful The Breast Reconstruction Guidebook (get this book!):
Breast Reconstruction Guidebook Table 18.1

Breast Reconstruction Guidebook Table 18.1

There’s also the Family Medical Leave Act, which applies to work protection and is not related to insurance coverage, but worth mentioning. FMLA entitles employees to take unpaid leave for family or medical reasons of up to 12 work weeks in a 12 month period and still have a job to come back to. There are some caveats to this one too. Read more about it on the Department of Labor site. Don’t forget Short Term Disability if you have that coverage. This will cover a portion of your wages, while you are out.

Whew, that was a lot. Did I forget anything?

Nipple tattoos

WARNING: NSFW / graphic content below.

I recently attended a local FORCE support group meeting. As always, it was fantastic! Our group meets quarterly, varies in size from five to 20, in age from 20 to 60ish, and is comprised of mostly previvors (in various stages: just found mutation to done with surgeries), but also women currently undergoing treatment, as well as survivors. There’s something for everyone facing hereditary breast and ovarian cancer to relate to. I highly recommend you find a group near you and attend at least one meeting. You may find that it’s not for you, but it’s worth a try. Find a FORCE group near you by visiting the local support page. Other organizations also have in-person support group meetings, so check with your doctor or do some googling.

Sometimes we have guest speakers come to share their research, work, products, or information relevant to our community. Our most recent guest was tattoo artist Amy Black of Amy Black Tattoos and Pink Ink Fund. Since 2011 Amy has been specializing in nipple and areola repigmentation as part of the breast reconstruction process for patients post-mastectomy due to breast cancer or as a prophylactic measure. Her 3D nipple tattoos look like the real thing! See for yourself below. Pink Ink FundAmy also founded the Pink Ink Fund shortly after beginning nipple and areola tattooing in response to seeing clients concerned about costs and having no health insurance. Amy’s work both in restorative tattooing and supporting the community is amazing! I plan on paying her a visit once I am done with my reconstruction. In addition to 3D nips, she also does touch ups, repigmentation, and artistic designs.

Here are some examples of her work:

1 5 4 6 3 2

Amy is located in Richmond, VA. If you are interested in contacting Amy, click here.

Healing well

WARNING: NSFW / graphic content below.

Elephant on chestSo far, so good. Things are looking good and healing well after my latest surgery two weeks ago when a tissue expander was placed on my right side. I am not loving the discomfort I have. Feeling no pain, but the tightness is definitely there! It is that elephant-on-your-chest feeling. Not as bad as after original mastectomy, but still very uncomfortable.

I have not been doing my stretching and range of motion exercises on a regular basis, so time to get back to those at least once per day. No lazy days! I am a fan of the Coach Casey Eischen post-mastectomy exercise program. She designed it specifically for women recovering from breast cancer related surgeries after she had her own PBM and noticed a void in this area. Check out FoobieFitness.com for exercise tips, videos, and nutritional information. Here is the video with level 1 & 2 exercises. These helped me a lot after my original surgery two years ago and each one after that.

And here’s my progress pic: two weeks after tissue expander placement on my right side (left in pic).

First expansion: March 4. Exchange surgery: July 23, 2015.

Breast cancer and diet, cleanse edition

At this point we all know that maintaining a healthy diet, exercising on a regular basis, and avoiding known pollutants and carcinogens in our environment are all key to optimal health. To that end, we all make related decisions in our lives based on what we believe.

There are no guarantees that if we live well, we won’t get cancer or another disease. But, there is enough evidence showing that how we live and what we eat can impact our health. Why not give yourself the best fighting chance you can to stay healthy?
-Dina Coleman (Top Nutrition and Lifestyle Tips for Preventing Breast Cancer)

I feel like I should take advantage of the little control I do have over my health. I maintain a whole foods, plant based lifestyle .. I would say I eat healthier than the average Jane. I’ve never been one for fad diets, with the exception of South Beach, which was the beginning of my long-term lifestyle transformation many years ago. I have done 30-day green smoothie and other similar challenges. My most recent endeavor was a 21-day cleanse. I went through that program back in November and am preparing to do it again now. Join me!

The Fresh Start 21 Cleanse from the girls at Simple Green Smoothies is a really great program! It can be purchased and completed at any time, but there are four “group” events throughout the year. The next group cleanse starts on Monday, February 2. The SGS crew partnered with a holistic nutritionist to create awesome and tasty dishes, a full 21-day meal plan, shopping lists, and a handy dandy cleanse guide. There is also a Facebook group for cleansers to support each other, offer tips, ask questions, commiserate. Having completed this once before I will say that this program is really worth the $59 (on sale). That’s a pair of shoes or jeans or a couple of dinners out. The food is wholesome, healthy, nutritious, and really tasty. I’m excited to it is all again. If you’re interested in exploring the whole foods menu or just looking for some fresh recipes, get more info here.

Long road of expansions ahead

WARNING: NSFW / graphic content below.

The follow up appointment after tissue expander placement surgery was Friday. The drain output was not high, but too close to Dr. M’s threshold for removal (50mL), so we decided to leave it in until Monday. I Had an opportunity to see how the incision is healing. So far everything looks goodt. I have been arnica montana and have very little bruising.

Low healthOverall feeling OK .. as long as I stay on my med schedule. Slowly trying to ween off of it, but not in a big hurry. Last night I didn’t set an alarm to wake up and take meds at night. Well, my body woke me up at 6 with a not-so-gentle reminder that I just had surgery. That was not pleasant at all.

The prune juice, Smooth Move tea, water, pears, and other fruit worked their magic. I went #2 on second day of recovery, but still have a bit of bloating and discomfort. TMI? If you’ve ever had general anesthesia surgery, then you understand how important this is. If you haven’t, then I hope you never do! Pain meds, no food/drink after midnight, inactivity, and anesthesia cause constipation. 

At the appointment Dr. M removed my dressings, which means I can now take a shower. I’m excited to do that today. Reviewing an old post (Shower time) and gathering supplies while I wait for hub to get home and help. This time around I didn’t get any tape or glue on my incision. If you recall, it was a suture knot that caused my last complication and the removal of the implant. To avoid that scenario, Dr. M used a single-filament type of suture (vs. braided) and only placed sutures and knots where absolutely necessary.

I also found out that my tissue expander is filled with 100ccs. We are filling all the way up to 550ccs, so that’s a long way to go. I start the expansion process six weeks post-op and will be getting fills every other week. In the past I have done 50ccs per fill, but may be doing a bit more this round to speed things up a little bit. Looks like July 23 may be just right after all.

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The day after

IMG_2641Yesterday was the seventh surgery of my breast reconstruction. I was a little worried, because of the snow, but it was just a dusting for us, so it still happened.

After three months uniboobin’ it again, I got a tissue expander on the right side. I don’t know yet how many ccs were put in with it. I will find out at my follow up appointment with Dr. M on Friday. The procedure took a little over two hours, as there was some scar tissue that also needed to be cleared away. I got a drain :(. Boo! This time it is not coming right out of the middle of my armpit, but rather on the side. Not complaining about that one. Armpit drains are no fun at all!!!

Yes, I am in pain today. It’s not as bad as initial TE placement after the PBM, but it’s not far from it. Staying on top of the pain by setting alarms on my phone and sticking to a schedule. Also popping Arnica Montana to minimize the swelling and bruising.

I tried to get ahead of the post-op constipation and started downing prune juice Monday. Have been eating lots of fruit, veggies, granola. Also drinking a lot of water, green smoothies, and Smooth Move tea. Fingers crossed that I go soon. No a fan of the bloating and discomfort. Got another pair of compression knee highs as well as the tread socks as hospital souvenirs. I’m sexy and I know it! Today I’m just lounging in bed, reading, Facebooking, and loving my BFF, the backscratcher.

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What’s next?

We wait six weeks for the body to heal and then start the expansion process. Once I find out how much was put in, I’ll have a better idea of how long this is going to take. I typically do 50cc expansions every two weeks. When we hit 550ccs I wait another four weeks before exchange surgery. Right now that is  scheduled for July 23, but I may be able to go sooner again. We shall see!