Law makes breast reconstruction insured
September 30, 1999
Web posted at: 3:14 PM EDT (1914 GMT)
By Kathleen Doheny
Doris Boyd expected a fight with her insurance company when she found out she had cancer in her right breast and needed a mastectomy. She had made up her mind that she wanted breast reconstruction immediately after the mastectomy and feared that her insurance company would not approve the plastic surgery.
"To have it done at the same time, it meant everything," says the 47-year-old resident of Guilford, Indiana, who had some difficulty coping with the reality that she was losing a part of her body.
To her amazement, the fight never materialized. Her group health plan, a preferred provider organization (PPO), covered about 90 percent of the bills, says Boyd, who works as an office supervisor at a bottling plant.
Like many women, Boyd was unaware of a new law, signed by the president a year ago this month. Called the 1998 Federal Breast Reconstruction Law, and sometimes referred to as the Women's Health and Cancer Rights Act of 1998, the law went into effect January 1. The law requires group and individual health insurance plans to cover reconstructive surgery after mastectomy, as well as implants and other work needed to make the other breast symmetrical.
Boyd, one of the first women to benefit from the new law, calls herself a lucky woman. "When I first started getting the bills and seeing what insurance was paying, I couldn't believe it," Boyd says. Her tab topped $20,000, including surgeons' and hospital fees for the mastectomy, concurrent reconstruction and an implant for the left breast to make it symmetrical to the right.
Many women may benefit
While no formal statistics are yet available, mastectomy-related procedures are expected to increase this year because of the new law. "In my practice, symmetry operations have at least doubled (so far this year)," says Dr. William Zamboni, professor and chief of the division of plastic surgery at the University of Nevada School of Medicine in Las Vegas.
In 1998, nearly 70,000 breast reconstructions were performed in the United States, with 39 percent of them done at the same time as the mastectomy, according to an American Society of Plastic and Reconstructive Surgeons' survey of its members, which constitute 97 percent of U.S. board-certified plastic surgeons. In 1997, more than 50,000 breast reconstructions were done, with 42 percent of them done at the same time as the mastectomy. This year, 175,000 American women will learn they have breast cancer, according to American Cancer Society estimates.
At the forefront
Spearheading the effort for the new law was Dr. Christine Horner-Taylor, a plastic-and-reconstructive surgeon in Edgewood, Kentucky, who dedicated her efforts to her late mother, who had breast cancer. The reimbursement situation now, she says, is "beautiful" in comparison to what it was. Horner-Taylor often argued with insurance companies on behalf of her patients who wanted reconstruction, sometimes tipping off the local television station to the story and winning an 11th-hour change of heart from the insurance company.
Initially, Horner-Taylor put her efforts into getting state laws in place to require that reconstructive surgery be reimbursed. But she discovered that a provision in existing federal legislation would exempt many company-sponsored group health plans from the state laws. So she stepped up her efforts to get national legislation, meeting with the president and setting up the Breast Reconstruction Advocacy Project. "It's been five years of my life," Horner-Taylor says.
Enforcing the law
Even with the new law, some obstacles remain. Not all insurance-company claims analysts automatically approve the coverage, perhaps because they are still unaware of the law, physicians report. In some cases, says Zamboni, approval "required a few reminder calls to certain authorization people in the insurance companies."
Dr. Glenn Davis, a plastic surgeon and clinical assistant professor at the University of North Carolina, Chapel Hill and Duke University, says he's had to do the same. But when insurance companies balk, he says, "We can now quote the law."
He sometimes meets resistance in collecting from Medicare, as well. For Medicare patients, reconstruction is payable when it follows removal of the breast for "any medical reason," says a spokeswoman for the Health Care Financing Administration, which administers Medicare.
Soon, the situation may improve. Davis says that implementation guidelines should be published within the year.
Copyright 1999 WebMD, Inc. All rights reserved.
RELATEDS AT :
The breast prosthesis
1998 Federal breast reconstruction act
National alliance of breast cancer organizations
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