How We Work With Insurance
in Washington, D.C. & Bethesda

How Plastic Surgery Institute of Washington Supports You

At the Plastic Surgery Institute of Washington, our board-certified surgeons and patient care team provide insight into how insurance works, what your plan requires, and how to navigate the reimbursement process. Many patients feel overwhelmed when searching for information about coverage, especially for procedures like breast reduction or post-weight loss surgery. We help you understand the path forward and equip you with the tools needed to advocate for yourself effectively.

Our Approach to Insurance

As an out-of-network provider with most insurers, we are not contracted with insurance companies and do not submit claims directly. However, we believe in empowering patients with accurate information. We provide the documentation required for reimbursement, help you understand your benefits and coverage requirements, and guide you in asking the right questions so you know what to expect from your insurer. This support reflects our commitment to patient-centered care, even in areas where coverage varies greatly.

Understanding Breast Reduction and Insurance

Breast reduction is one of the few procedures in plastic surgery that insurers may classify as medically necessary. Each insurance plan has its own criteria, which may include documented symptoms, conservative treatments, gram weight tissue requirements, and photographic evidence. We help you understand your plan’s criteria and gather the documentation insurers commonly request.

We also maintain updated guideline copies for many insurance companies to support patients who want to better understand their insurer’s requirements before moving forward.

What to Know About Breast Reduction and Insurance Coverage

• Medical necessity criteria: Insurers typically assess symptoms such as neck and back pain, skin irritation, and activity limitations, along with documentation of non-surgical interventions and surgeon-measured tissue removal estimates.
• Required documentation: Insurers often request recent medical records, measurements, photographs, and a detailed history of treatments attempted prior to surgery. Our team guides you in preparing what your plan requires.
• Coverage limitations: Even when a procedure meets medical necessity guidelines, some plans exclude specific procedure codes or limit reimbursement amounts. Understanding these limitations helps prevent unexpected outcomes.

Filing for Reimbursement: What to Expect

Patients with out-of-network benefits typically pay upfront and then file directly with their insurance for potential partial reimbursement. We provide the necessary documentation for your claim, while all communication and submission requirements should be handled directly between you and your insurer.

Before surgery, call your insurance company to confirm:

• Out-of-network deductible: Clarify your deductible amount and how much remains for the year.
• Out-of-network co-insurance: Confirm the percentage your plan covers after your deductible.
• Valid procedure codes: Ask whether your procedure is billable under your plan and whether any exclusions apply.
• Claim submission process: Request instructions for filing, required forms, and accepted submission methods.
• Required documentation: Verify whether your insurer needs any materials before your procedure date.

If your facility and anesthesia providers are in-network but your surgeon is out-of-network, coverage may be affected. Your insurance company can explain how your plan manages situations involving mixed provider status.

Claims often take several months to process and may require additional documentation or appeals. Reimbursement is based on the insurer’s allowable amount, minus deductibles, co-pays, and co-insurance. This amount is usually far lower than the procedure’s self-pay cost. Our fees do not change based on reimbursement.

How We Support You Throughout the Process

Our team helps you understand insurance guidelines, navigate the reimbursement process, and understand your financial responsibility. While we do not submit claims on your behalf, our office does take care of any prior authorizations or pre-determinations that may be required by your insurance. In addition, we will assist by confirming our facilities’ in-network status with your insurance and informing you when in-network benefits may be applied. Our goal is to ensure you have accurate information, clear expectations, and the documents required to file confidently.

Your Next Step Toward Clarity and Confidence

Insurance can feel complicated, but you don't have to navigate it alone. At the Plastic Surgery Institute of Washington, our guidance reflects the same attention to detail, professionalism, and patient support that define our surgical care. We help you understand what your insurer requires and how to prepare for the reimbursement process with confidence. Schedule your consultation today to learn more about your options and how our team can assist you.