breast forms and insurance

If your insurance company is indeed contractually required to pay 100% and is refusing to do so, your employer may have a human-resources specialist who can do the troubleshooting for you. I finally turned my records over to the person at work who does this, and it turned out that there was no way I could have done it on my own. As a mere subscriber, I could reach only insurance-company employees who were paid to put me off. As the professional in charge of my company's insurance, my human-resources person could reach a higher, decisionmaking level. I managed to get all the money I was owed. But it was a lot of work since I had to organize the paperwork and explain all the shortfalls to the human-resources person so she could pursue it. By the way, you may want to experiment with improvising your own forms and bras. There are threads on this board about making your own microbead forms and adapting ordinary camisoles and sports bras to hold them. Plus some camisoles come with pockets (Lululemon yoga tanks do, and they;'re not too expensive if you buy them on sale). I find my homemade items more comfortable and just as real looking as the specialized stuff.

I, too, got a "surprise" bill from the mastectomy supply store after I thought I'd paid them what I owed.

My mast bras and breast form were covered under the "Major Medical" provision of my health insurance, which is a group plan administered by BC/BS.  The annual coverage goes by calendar year (Jan-Dec).  I pay 100% until my deductible is met, and after that I pay 20% of the "allowable" amount.  (I don't know the actual name for that, but it's basically what my insurance company says is the reasonable cost for something, based on bids or competing vendors or something.)  The mast supply store I used advertised that they billed BC/BS directly.

I bought my bras and breast forms late in the year, after I had already met my deductible, which I think was around $100 back then. When I went to the cashier to settle the bill, she calculated what I owed based on what my insurance would allow for bras and a prosthesis and what my co-pay would be on that allowable amount.  So my bill consisted of my 20% (my co-pay) of the "allowable" amount, plus the difference between what my insurance considered the "allowable" price and what the bras and prosthesis actually cost.  It was quite a lot -- I could have bought 4 or 5 of my regular, pre-BC bras for what my out-of-pocket cost was that day.

About a month later, I got another bill from the mast supply store, with a note saying it was what I owed after the "settlement" with my insurance company.  This was in addition to what I had already paid!  I never did figure out what happened, and I was too confused and ticked off to call and complain.  I had heard there were stores that would do what this store was doing. 

It works differently with my doctors and hospital charges -- almost all of those are "preferred providers," which means they have an agreement with BC/BS to accept whatever BC/BS says is the "allowable" cost for the service.  I might owe a deductible or a co-pay out-of-pocket, but as long as the service is from a preferred provider, I cannot be billed any additional charges even if the actual cost is higher than the allowable cost. 

I guess I learned the hard way that the mast supply store I used was not a "preferred provider." The deductible for my Major Medical coverage has gone up to $300, which would pretty much pay for any prosthesis I would buy in the future.  So I think I'll just pay cash next time -- maybe I can negotiate a lower "cash" price!

otter

This question is about breast forms and does not have anything to do with insurance.  Does anybody use adhesive forms?  I haven't, and unless I have a sports bra on, the side with the prosthesis kind of hangs out when I am in "downward dog" or forward bend".  What adhesive forms are good?  Will they stay put even on a hot sweaty day?

Houndmommy,

Terri is right, the thepinkbra.com has prices lower than what you're likely to pay at a regular retail shop. It's also true that almost all online sites, not just that one, feature lower prices than your local retail establishment. Unfortunately, in my experience the online sites don't process insurance for you. You'd have to purchase the items yourself and then submit to your insurance company, which can be a hassle. For that reason, I normally buy my annual insurance allotment of breast forms and bras at my local shop, then if I want to supplement that I use the online sites.

MetroMedicalOnline and Park Mastectomy are examples of other online sites that also offer lower prices.

Barbara

BreastFree.org