My new PPO takes effect in November, in general do PPO’s cover rhinoplasty if the reason for surgery is due to a deviated septum?
Great question and one that many patients and even doctors are unsure about.
First off we have to establish some facts.
As far as Rhinoplasty cost, there is a large variation. The range for Rhinoplasty cost nationally is anywhere from $2000 to $30,000. That cost for Rhinoplasty depends on the geographic location with NYC, LA and Chicago being the most expensive but also on the skill and popularity of the Rhinoplasty surgeon. With that said, there are some highly over-rated and over-priced surgeons out there.
Now another fact: Insurance rarely if ever pays for the work a doctor or surgeon does. Insurances, whether private or government run, are what you would consider “dead beat payers.” What that means is that they pay what they want to pay and not what a highly trained doctor with years of education and dedication deserves to get paid.
For example, a Head & Neck cancer surgeon can do a 14-20 HOUR operation standing on his feet the entire time performing life saving intricate surgery and expect to get paid about $2000 while a Dermatologist can make the same money in 15 minutes doing some Botox injections!!!
The reason I am telling you this back ground information on insurances and what and how they pay doctors is this: INSURANCES WILL NOT PAY A FAIR COMPENSATION FOR A SURGEON’S WORK. THEREFORE MOST HIGHLY SOUGHT AFTER SURGEONS WILL SET THEIR OWN PRICE FOR THEIR OWN SKILLS AND SERVICES AND WILL NOT SETTLE FOR GETTING PAID 15-25 CENTS ON THE DOLLAR. Now other less popular or busy or in-demand surgeons who are looking for the patient volume will sign up with insurances and take whatever insurance will give.
What I am saying is a generality but it applies to a wide range of doctors and situations.
Now to get more specifically to your question about Rhinoplasty, Septoplasty and insurance coverage:
PPO vs HMO essentially is about the ability to see a specialist without a referral from the “gate keeper” who is usually the Family Doctor. Thats pretty much it.
All insurances SHOULD pay for Septoplasty if there is septal deformity and nasal airway obstruction symptoms. Now they do not always because like all insurances (auto, life, health, etc…) they try to get out of paying whenever they can. But the vast majority of cases, your insurance should pay for the Septoplasty.
If all you are getting is a Septoplasty then there should be no additional cosmetic out of pocket fees. But if you are getting ANY kind of cosmetic work as well, then YOU have to pay for that part.
Now, the reality is that many surgeons will do your Septoplasty and bill it to insurance and ask for another $1, 2, or 3k on top of that for the cosmetic Rhinoplasty. But insurance pays $500-1200 for a Septoplasty so if you do the math you will see that these doctors collect a total of $2-4K for the entire procedure.
Well there is no way you will be able to convince a busy Rhinoplasty Surgeon who charges $10-30K for a Rhinoplasty to do your surgery PRIMARILY through insurance.
So these surgeons will do your Septoplasty through insurance but you will owe a large portion out of pocket for the cosmetic work. The benefit of seeing a dedicated Rhinoplasty Surgeon even though you are still paying a HUGE chunk out of pocket is that you are getting the best possible cosmetic Rhinoplasty surgeon while insurance may cover a small portion of the surgeons fee as well as about half of the hospital and Anesthesia fees (the portion related to the Septoplasty).
At the end of the day the choice is yours. If you have insurance then it makes sense to use it – most situations, not all.
But you have to know that well known Rhinoplasty surgeons will demand a significant out of pocket fee for the cosmetic work.
Also be aware of the “shady surgeons” who will commit insurance fraud by adding on extra unnecessary procedure codes to try to get insurance to pay for the whole surgery.
I hope this helps clarify the mystery. It is complicated to say the least.