The Women’s Health and Cancer Rights Act of 1998 mandates insurance coverage for breast reconstruction after mastectomy, but that does not mean that getting your procedures covered is simple. Health insurance varies by state, carrier, plan, and more. We sat down with BRAVE Coalition Foundation health insurance expert, John Gwin, to dive into the details of the WHCRA’s legal protections and what you can do to get your breast reconstruction covered.
BRAVE Coalition Foundation is a non-profit organization that aims to ensure everyone impacted by breast cancer has the knowledge, resources, and community support necessary to confidently navigate their options around breast reconstruction and restoration. They focus on health insurance coverage in an effort to remove financial barriers to breast reconstruction.
Read on for tips on how to navigate, self-advocate, and otherwise problem-solve in the face of common health insurance obstacles.
Q: What is the Women’s Health and Cancer Rights Act of 1998?
A: The Women’s Health and Cancer Rights Act of 1998 (WHCRA) is a federal law that mandates group health plans and health insurance issuers offering coverage for mastectomies to also provide coverage for breast reconstruction, prostheses, and treatment of physical complications, including lymphedema. What does this mean for consumers? It offers more protection than almost any other type of care a person could seek out in the US, because it is protected by a federal mandate. That said, this does not mean coverage does not come without some of the same hiccups we all deal with on the insurance end every day.
Q: What were the intentions behind the law, and how have those borne out in its execution over time?
A: The intention is to protect women battling breast cancer from denials and coverage gaps throughout their journeys. Despite the intent, payers still often play games and attempt to deny care at different degrees and different steps in the process depending on the patient’s situation and type of coverage. In the end, this doesn’t change the process of claims processing and insurance billing, but does make coverage more accessible and give patients and providers a big stick to wield in the event there is a denial or obstruction.
Q: How can patients leverage the rights the law does provide?
A: The first step is to be familiar with your rights. Know what the law provides and what it means for your specific care. If you experience issues, ensure that you and your provider are citing and leveraging the law as you correspond with the payer (your insurance provider) to let them know you do know your rights. At the end of the day, this is a law, so it also provides a clear avenue for legal recourse should it become necessary. That said, ideally, we can avoid the legal avenue as the payers behave better when the Act is cited throughout the claims processing steps.
Q: What is the difference between a covered service and one that is reimbursed?
A: Coverage does not equate to reimbursement. That means that although the medical necessity of the treatment, service, or device may be clear and accepted, patient benefits are still applicable. By patient benefits, we mean deductible, coinsurance, copay and out-of-pocket maximum owed.
For example, if you have a reconstructive surgery post mastectomy with an allowable billed amount of $1000.00 and a $0.00 deductible plan, you may owe nothing at all! But, with that same treatment or service and a $500.00 deductible plan with $0.00 paid thus far this calendar year, you would likely owe $500.00 as part of your deductible.
Q: Let’s talk problem solving: how can you deal with non-medically necessary denials or bills on an individual basis?
A: If you receive a bill from a provider, first confirm why you received it. You should have an Explanation of Benefits (EOB) from your insurance company and/or you can often locate these on your phone application or payer web portal. If you have a deductible that has not been met and the bill you’ve received is less than or equal to your remaining deductible, the bill is probably a legitimate and you should not waste your time fighting it.
If you have been denied a claim on the basis or medical necessity, the first step is to ensure that you agree whether or not the service is medically necessary. Look up the Medical Policy as it pertains to the services rendered. To find the Medical Policy, most payers will have a search engine to an internal website that references “what is covered.” Sometimes you can even use Google to search “Insurance Company Name + Service/Treatment Medical Policy” and it will often yield an accurate result. If you cannot find it, navigate to the payer website and use their internal search engine. In the worst case scenario, you can call member services and ask them to help you find the URL. If your insurance provider deems a claim is not medically necessary but you believe that claim is covered by the WHCRA, ensure that there is no misalignment between the Act and the Medical Policy. If there is, the Act will supersede.
In addition to advocating for yourself with your health insurance company, you should contact the provider who is billing for the denied claim to see if they will fight for you. Be sure to monitor their action. Ask for copies of what was sent to the payer and request that they explain the argument to you. If you think they’re doing a good job, let them push the path forward for you. If you do not believe they are doing a good job, you are your own best advocate at the end of the day, push! Push with them, with the payer, with your employer if the insurance is employer-sponsored. Contact an attorney if you’re at your wits’ end. You can also seek assistance from third parties like BRAVE or BreastReconstruction.org who often have billing experts to help you navigate these waters.
If you receive a bill you don’t believe is valid, be sure you let the billing provider know you will not pay until and unless the situation is handled appropriately. Be sure that you are being fair/equitable based on the WHCRA and the process.
If a provider does threaten to send you to collections, keep in mind you have rights there, too. They cannot send you without due recourse and appropriate action or they may put themselves in hot water. Also, collections agencies cannot report you to credit bureaus unless the bill is accurate, so let them know it is inaccurate, and provide them with a record of your fight with the provider and payer.
Q: Breast and plastic surgeons typically work as a team, along with other medical professionals, like Physician Assistants. What do you do if only part of your team is covered? And what happens if someone who is out-of-network enters the OR while you are in surgery?
A: Keep in mind you may get a bill for one single surgery from:
- Plastic Surgeon (MD)
- Assistant Surgeon or Physicians Assistant or Surgical Technician
- General Surgeon
- Anesthesiologist
- Facility
- Lab
These bills could be bundled or independent. That means that an employed physician and facility bill may be on the same medical bill, or they could be separate the bill involves a private practice surgeon and a hospital. This is totally normal and, yes, frustrating, because it is not typically a question you would ask up front. It is also not something that you or your team can change. If you have a great team of practitioners that are all in their own individual private practice, you will have more fractured billing. This isn’t a bad thing necessarily, but it creates more potential areas for errors you need to monitor as a consumer.
If only part of your team is covered, you have to again, look at the “why.” For example, it would make zero sense if your provider’s claim was billed for medical necessity, but your facility bill was not. Now we fight! But, if your provider was in-network, and your assistant surgeon was not, then you have to look beyond the WHCRA to different legal protections, like the No Surprises Act, and you can still fight it, but in a totally different way. The No Surprises Act protects patients from “surprise bills” from providers who are not in-network. It applies to all service types and requires out-of-network providers to disclose pricing up front.
Q: We’ve seen a lot in the news in New York about large health systems suddenly refusing to work with specific major insurance companies. How can patients navigate these kinds of changes, especially when breast reconstruction often involves many surgeries over the course of months or years? How can you maintain the same team when your insurance or the insurance that one or all members of your team accepts changes?
A: In short, this is near impossible to monitor without asking your providers and checking with your insurance company. Before you go into surgery, ask your providers and confirm if everyone involved is in-network. Get names and NPIs (think social security number for medical providers) and check with your insurance company to confirm. Be sure that for any out-of-network provider, the payer has provided an agreement that they will treat you as in-network for this case for “continuity of care” so you can keep your surgical team together. In cases where a patient has a staged procedure and a provider changes network status in the midst of care, the payers will allow you to be treated as in-network so long as they are pushed to do so before surgery.
Q: What does it mean to try to access people at the highest level when self-advocating?
A: At the end of the day, you have to be noisy and persistent. You may need to call the corporate office at your payer and deal with those phone trees that go nowhere. Each state has a Department of Insurance where you can file complaints (with some limitations based on your plan type). You may need to take to social media. Hit the payers on X, Facebook, Instagram, LinkedIn with comments. They stay concerned with problems that are visible to the public much more aggressively than those managed privately. It can be a bit embarrassing to have your “business out there,” but I assure you that social media posts will get replies. Last, but not least, leverage an attorney. It will cost you a few hundred dollars to get a “nasty-gram” sent to the payer, but it will reach their legal department and will get you attention as well if you’re able to afford the cost. At the end of the day, do not take no for an answer if the answer is not right.
