I draw a hard line between cosmetic and functional whenever possible. Because of the prevalence of cosmetic eyelid procedures performed in the United States, I am not infrequently audited by insurers, including the federal government, to make sure that I am not billing them for anything cosmetic. My last audit was April 2017, and I am happy to report that I could easily defend all of my surgical decision-making, and none of my surgeries for Medicare were denied retroactively. And none of my patients are going to get a surprise bill in the mail. I tell it to patients like this: “I do a lot of surgery, and Medicare is definitely going to audit me. That is why I cannot do your surgery and submit it to Medicare if I don’t think it is covered. You might be able to go out and find someone who does less surgery, and therefore is less likely to be audited. That person might just do your surgery and bill Medicare for it. And it might work out for you. But, then again, you will be going to someone who doesn’t do a lot of surgery. Your choice.”
I will absolutely bill patients for services if the claim gets denied. Of course, I will go through formal appeals processes to the full extent possible, prior to sending a bill to patients. For patients with commercial insurance that are “borderline”, I submit them for prior authorization by the insurance company. A few times a year, the “prior authorized” cases get denied after surgery. Yes, you read that right. In these instances, I absolutely do bill those patients with whom I have had an up-front discussion about their financial risk prior to undergoing surgery.
I make all patients who are undergoing eyelid surgery sign an “advanced beneficiary notice”, or “ABN.” This states how much I am going to bill them if their insurance denies their claim. This is important, because Medicare does not “prior authorize” procedures: they rely on me to verify that the patient’s condition meets their local criteria for care. (This is why going to a plastic surgeon, versus an oculoplastic surgeon, for an insurance blepharoplasty, is a dicey proposition — they are less capable of making this assessment.)
I will do my best to prevent any financial surprises for patients. But occasionally patients are disappointed with their insurance company, or with Medicare. I cannot control that.