Reconstruction and Champva

2tuff2quit

In 2009 I had a double mastectomy with Tram Flap Reconstruction with terrible results including a staph infection.  After 9 surgeries the first year, I have been wary, until recently, to have my breast reconstructed again.

My insurance, Champva will pay 100%, so I thought that meant 100% of the plastic surgeon's bill.  Found out from the insurance specialist at the surgeons office that out of the $30,000 bill, the total insurance paid will be approximately $1,500 because Champva pays just so much per surgery code.  The doctor won't do the 4+ hours surgery for $1,500 and wants me to pay an additional $7,000.

My question is, do any of you understand why insurance that pays 100%, in reality pays 5%.  I need help understanding how an insurance process works.  Need the surgery before the end of year to avoid additional money for deductable.

Thanks in advance

SpecialK

I use Tricare but similar rules apply if your physician accepts you as a Champva patient. In agreement with Champva the provider accepts the allowable rate for the procedure and cannot balance bill you for the difference. The exception is if the doctor does not accept you as a Champva patient, demands the payment in full up front, then you bill Champva yourself on a claim form for personal reimbursement. I think the "100%" is misunderstood - to me it is interpreted as the bill is 100% paid in that the provider is agreeing to accept the reimbursable rate as payment in full. The provider can't have it both ways - by billing Champva, accepting their payment, then expecting the balance from you. Here is a link with the explanation. Note that this is information for providers and read the section on page 2 about accepting the allowable rate:

http://www.va.gov/hac/factsheets/champva/FactSheet01-16.pdf