Many insurance companies classify a breast mastectomy as same-day surgery (the “drive-through mastectomy”), and refuse to cover an overnight stay in the hospital. This serious surgery, requiring a general anesthetic and resulting in potential side effects like pain, bleeding, and infection, demands close monitoring by medical professionals for at least one day.
A federal bill to mandate at least a 48-hour hospital stay after mastectomy, the Breast Cancer Patient Protection Act of 2016, has been stalled in Congress for over a year. If you want control over the length of your hospital stay post-mastectomy, it’s up to you to be proactive.
How do you ascertain the amount of hospital time your insurance company will cover after a mastectomy? And what do you do if you feel it’s insufficient?
Know your state law
Each state sets a minimum hospital stay for any kind of surgery, and insurance companies operating within that state are required to follow the law. This applies to insurance coverage offered through an employer. State law may or may not apply to private insurance (individual insurance bought on the private market, not through an employer). And state law doesn’t apply to coverage you get through your employer if it’s “self insurance” — i.e., not provided by an insurance company or HMO.
Are you covered by federal health insurance? Medicare doesn’t mandate a minimum hospital stay for a mastectomy. And Medicaid coverage varies state by state.
How do you find out whether your state has a minimum-stay requirement for mastectomies? Contact your State Insurance Commissioner’s office. The National Association of Insurance Commissioners (NAIC) website offers an interactive map with contact information. Or give the NAIC a call, 1-866-470-6242.
Nail down the details of your surgery
Before calling your insurance company to discuss coverage of your mastectomy, clarify what your actual surgery entails. Are you having a simple mastectomy, with no immediate reconstruction? Will the surgeon create a space for implants, and insert an expander? Are you having total breast reconstruction, using tissue from another part of your body?
Each of these surgeries is viewed differently by insurance companies. Many insurance companies term simple mastectomy an outpatient procedure. But further work to prepare for implants may require an extended stay; and the plastic surgery required for reconstruction is additional surgery. So when checking on what your insurance company will cover, be sure the company representative you speak with understands the full extent of your surgery.
Understand what your insurance company offers
Some insurance companies define outpatient surgery as “same day:” Enter in the morning, exit in the evening. Some offer a 24-hour window: Enter in the morning, leave the next morning. And some extend that hospital time to 36 hours: Enter in the morning, leave the following evening. Clarify what’s on the table; if you’re having a simple mastectomy and can remain in the hospital for 36 hours, that may be totally sufficient.
Gauge your own comfort level
How do you generally respond to surgery or other serious health issues? Do you rebound quickly? Is your pain tolerance high? You may prefer leaving the hospital as soon as possible, feeling you’ll recover better at home.
But what if you have small children to take care of at home? Or you’re elderly, and live alone? You may need the rest and support extra time in the hospital offers. Deciding ahead of time how long you’d like to remain in the hospital can guide your conversation with the insurance company (or your doctor).
Get help from your surgeon
If your insurance company will cover only a short hospital stay, and you feel you’ll need longer, speak with your surgeon. Many surgeons are willing to help with insurance issues by recommending a certain length of hospital stay. If your insurance company balks at an overnight stay, ask your surgeon if he or she can code the surgery in a way that bypasses the insurer’s automatic time limit for mastectomies.
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