How a Plastic Surgery Practice Recovered $890K in Reconstructive Cases
Distinguishing medically necessary reconstruction from elective procedures
Reconstructive Surgery Practice
Reconstructive Surgery Practice
About
A specialized plastic surgery practice focusing on post-mastectomy reconstruction, burn repair, and trauma reconstruction, serving patients across the Southeast.
Industry
Plastic & Reconstructive Surgery
Company size
25-35 employees
Headquarters
Charlotte, NC
Founded
2011
Annual Claims
$8M+ billed annually
Key Features Used
Challenge
Plastic surgery practices face a unique stigma: payers often assume all procedures are elective cosmetic work. The practice's reconstructive cases were being denied or severely underpaid despite being medically necessary procedures for cancer survivors and trauma patients.
Solution
Use Clearest to build comprehensive documentation packages that clearly established medical necessity for reconstructive procedures, supported by peer benchmark data from other reconstructive surgeons and federal parity requirements.
Illustrative Results
$890K recovered
Revenue recovered in 10 months
92% win rate
On reconstructive case disputes
58%
Average increase in reimbursement
73 cases
Successfully disputed
The reconstruction reimbursement gap
Reconstructive plastic surgery is fundamentally different from cosmetic procedures. When a woman needs breast reconstruction after cancer, when a child needs facial repair after a dog bite, when a worker needs hand surgery after an industrial accident, these are medical necessities, not elective choices.
The practice owner had built her practice around helping these patients. But payers routinely treated her claims the same as cosmetic procedures, denying coverage or paying rates that barely covered operating room costs.
The Women's Health and Cancer Rights Act mandates coverage for post-mastectomy reconstruction, yet payers found endless ways to underpay. The practice was spending more time fighting insurance companies than performing surgery.
Illustrative perspective
My patients had already fought cancer. They should not have to fight insurance companies just to feel whole again.
Proving medical necessity
The key to reconstructive surgery disputes is comprehensive documentation of medical necessity. Clearest built evidence packages that included clinical photographs, pathology reports, surgical notes, and quality-of-life assessments.
Each case clearly distinguished between reconstructive procedures, which restore function or normal appearance after disease or injury, and cosmetic procedures, which enhance appearance without medical indication.
The platform also tracked federal and state parity requirements, ensuring disputes cited relevant mandates for coverage of reconstructive surgery.
Leveraging federal mandates
Post-mastectomy reconstruction cases were particularly successful. The Women's Health and Cancer Rights Act provides clear federal requirements, and payers who denied or underpaid these cases faced strong legal exposure.
Clearest's benchmark data showed what other reconstructive surgeons received for identical procedures, making the underpayment obvious to arbitrators.
Illustrative perspective
When we could show that a payer was violating federal law by underpaying reconstruction, they suddenly found room in their budget.
Expanding access to reconstruction
The $890K recovery allowed the practice to hire an additional surgeon and expand reconstructive services. The practice now offers free consultations for uninsured breast cancer patients, funded by the improved collections on insured cases.
The success also changed how the practice approaches documentation. Pre-operative photos, detailed surgical plans, and quality-of-life assessments are now standard, preventing denials before they occur.
Illustrative perspective
Clearest helped us build a practice that can serve more patients who need reconstructive care. That is what this work is really about.
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