Plastic Surgery Medical Billing is Necessary for Streamlining the Revenue Cycle

Plastic Surgery Medical Billing is Necessary for Streamlining the Revenue Cycle


Since ages, people have a never-ending wish of enhancing their appearance and always look beautiful. But unfortunately, with age or due to an infection, the skin does not retain its look, and people have to take medication or consult a dermatologist if the skin condition aggravates.

Why Plastic Surgery has become so Popular

In modern times, the trend of plastic surgery has increased tremendously and refers to the surgical procedure of reconstruction of facial skin or body skin damage due to burns, diseases, congenital disabilities, or trauma. Plastic surgery is reconstructive in nature and includes many popular procedures such as

  • Breast reconstruction
  • Cleft Palate repair
  • Scar revision
  • Burn repair

According to the American Society of Plastic Surgeons (ASPS), Americans spent nearly $16.5 billion on plastic surgeries in 2018 alone. The $16 figure is quite staggering considering the medical bills and all the procedural and consultation fees.

But who is paying for all the plastic surgery costs?

The answer depends on the insurance coverage one has, the insurance provider's terms, and the extent of surgical procedure required. However, it is essential to determine if plastic surgery is covered or not and also depends on

  • If the surgery is reconstructive or cosmetic
  • If the procedure is necessary for body function or enhances the quality of the skin

The insurance policies differ from one provider to another, and there are many changes in the guidelines as to what defines a reconstructive or cosmetic surgery. Most insurance companies follow the guidelines defined by ASPS and the American Medical Association (AMA). The difference between reconstructive and cosmetic surgery is stated as

  • Any surgical procedure performed to treat developmental abnormalities, infection, diseases, tumors, or trauma is considered ‘reconstructive surgery.’
  • Any non-surgical or surgical treatment to enhance the skin's appearance or shape is regarded as ‘cosmetic surgery.’

Does Your Insurance Plan Cover Plastic Surgery Procedures?

The insurance provider can change the rules of the policy over time depending on the type of insurance plan one has, the needs of the patient, and the progress of modern medical and procedural treatments. Most of the insurance companies do not cover the various cosmetic surgery but do cover reconstructive surgery.

There is a fine line that differentiates plastic surgery from cosmetic surgery, and more than half of the medical bills fall under ‘cosmetic,’ and the medical practice can claim it in cash and reimburse. But the medical bills for reconstructive surgery are complicated and need to be filed with the insurance provider and get accepted or rejected based on the bill's authenticity and accuracy. Some of the common plastic surgery procedures that are usually covered include ‘Reconstruction surgery, Laceration repair, Scar revision, Lip repair, and Post mastectomy surgery.’

There are many things to consider and decisions to make for an individual thinking about plastic surgery, such as

  • What procedure to select
  • Locate the skincare facility or medical practice that provides the required surgical procedure
  • Finding and consulting with a qualified and experienced surgeon
  • The total cost of diagnosis, treatment, and consultation

Before signing up for plastic surgery, one has to spend time and research on the average costs of the surgery that needs to be performed. The trend of plastic or cosmetic surgery is booming, and there is an emphasis on medical billing not only by the medical practices but also by the patients.

The Importance of Medical Billing Software for Plastic Surgery Treatments

The primary goal of a surgeon’s clinic or medical practice is to effectively treat or enhance the patient's skin and bill the entire process correctly for full payment of the services rendered. The plastic surgery procedures are quite expensive, and the large amounts make the insurance companies work and analyze the medical bill from every perspective. The best solution is to either install an advanced medical billing software or outsource the billing service.

It is commonly known that insurance companies reject more than 50% of the medical bills on the accuracy and authenticity of the medical codes used to make a claim. It is not uncommon for an insurance company to verify a large amount of plastic surgery treatment and pay only a portion instead of the full payment.

Plastic surgery comprises many treatments, and it could be complicated for a medical practice or skincare facility to deal with hundreds of CPT (Current Procedural Terminology) codes. Things can get further complicated if the medical claim is rejected. National Correct Coding Initiative (NCCI) edits are required to avoid incorrect payment requests when the given medical bill is rejected due to incorrect code combinations.

The selection of E/M (Evaluation and Management) codes, add-on codes, and modifier codes is not an easy task apart from the CPT codes and Healthcare Common procedure Coding System (HCPCS) and makes it mandatory for plastic surgeons to integrate a sophisticated medical billing software solution.

There is no one software solution that fits all, as the policies of each medical practice, or the surgeon’s clinic has different operational guidelines. The terms with the insurance provider also vary from one health center or surgeon facility to another.

Medical billing is an essential part of the revenue cycle that helps to generate the financial resources needed to manage the operations, from medical practitioners’ salaries to payment of overheads. The most challenging or crucial part is when the medical bill is filled initially, and the insurance provider denies the claim and withholds the full payment. It takes medical practice quite some time to correct the objection raised by the insurance company.

Unfortunately, many insurance providers know that medical practices are busy caring for the patients and have little time or expertise concerning the various complexities of medical billing and coding. However, advancements in technology have led to innovative medical billing software that includes many value-added features and can easily integrate with the existing management system of the health center.

Advantages of Implementing a Software Solution

Plastic surgery medical claims are quite profitable, but a lack of expertise in billing function can lead to the practice losing tens to thousands of dollars. Customized billing software will help to

  • File the medical bills accurately
  • The CPT codes are pre-loaded and get automatically updated, which significantly reduces the risk of claim denial
  • Electronic submission of medical claims
  • Efficient follow-up with the insurance provider
  • The rejected claims are checked quickly and adjusted that ensures maximum payment
  • Boost the reimbursement and revenue cycle

PETTIGREW is an established company that provides a wide range of customized revenue management, billing, coding, and staffing solutions. The company employs skilled software developers and billing specialists who help design and develop a software that efficiently fits the medical practice needs. The software solution is designed to follow the HIPAA (Health Insurance Portability and Accountability Act) guidelines and comply with other government, insurer, or third-party policies.

The modern software is secured and offers cloud services that allow remote medical billing and reporting. Medical practice, not having a robust and efficient billing system, can lose up to 20% of its potential revenue. The payment collection for plastic surgery treatments is unlike the regular diagnosis and treatment due to the patients' large balances and the complexity of the procedures.

The patient’s insurance eligibility is checked beforehand during the appointment scheduling, which helps the medical practice review the coverage plan in advance and ensure full payments and no delays or rejections from the insurance providers. To streamline the revenue flow, the medical practice or skincare facility must accurately document diagnosis, treatment, results, and consultation to get proper reimbursements.

Although a customized software allows to reduce the errors and streamline the billing process, one of the critical challenges is pursuing ‘underpayment.’ The clinic may get reminders to send new bills and track the underpaid accounts, but the team must be trained to handle and do regular follow-ups that can help get maximum repayments.