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Post date: May 1 2014

A.G. Schneiderman Announces Agreement With Empire BCBS To Help Women Who Undergo Breast Reconstruction After A Mastectomy

Agreement Provides That Empire Will Approve Out-Of-Network Exceptions For Breast Reconstruction Surgery In Certain Circumstances

Schneiderman: Strengthening Consumer Protections Will Help Members Focus On Health And Recovery

NEW YORK - Attorney General Eric T. Schneiderman announced today a best-practices agreement with Empire BCBS, which implements new protections for Empire members who undergo breast reconstruction following a mastectomy. The agreement requires Empire to fully cover an out-of-network plastic surgeon, if no in-network plastic surgeon is available at the hospital where the mastectomy surgeon has scheduled the surgery. In addition, Empire will provide earlier and better notice about network providers and procedures for requesting an out-of-network exception.

“Undergoing reconstructive surgery following a mastectomy is a stressful experience, and insurance companies must strive to make it as smooth as possible for their members,” Attorney General Schneiderman said. “By agreeing to strengthen consumer protections, Empire will help allow their members to focus on the most important thing – their health and recovery.”

In order to minimize patient risk, physicians often advise mastectomy patients to undergo breast reconstruction surgery immediately after the mastectomy, during the same surgical procedure setting. New York and federal law require plans to cover post-mastectomy breast reconstruction in the manner determined by the attending physician and the patient to be appropriate.  

When an in-network mastectomy surgeon teams up with an out-of-network breast reconstruction plastic surgeon for surgery at an in-network hospital, the patient often seeks an out-of-network exception request, so she can pay the same fee as she would if the plastic surgeon were an in-network provider. Empire, however, had denied some of these requests, and instead directed the patients to use an in-network plastic surgeon. At times, these denials resulted in the patient relocating to a different hospital with an entirely different in-network surgical team than the one the patient and the mastectomy surgeon chose. Delays also ensued.

The agreement helps women stay with their medical team and requires Empire BCBS to: 

  • Grant a request for an exception for an out-of-network breast reconstruction plastic surgeon when the in-network mastectomy surgeon refers the member to an out-of-network plastic surgeon, but no in-network plastic surgeon is available at the in-network hospital where the surgery is to be performed, and the out-of-network plastic surgeon has entered into a single-case agreement with Empire;
  • More fully and promptly advise the member of critical information regarding Empire’s networks, and notify the member during the first medical appointment with the mastectomy surgeon of the right to request an out-of-network exception; and
  • Include more information in denial letters, including the identities of available in-network plastic surgeons, their specialties and contact information, as well as the identities of other members of the in-network medical team. 

Consumers with a complaint regarding health plan practices, or any other health care issue, are encouraged to contact the Attorney General’s Office Health Care Helpline at 800-428-9071.  

The investigation was handled by Assistant Attorney General Carol J. Hunt and Lisa Landau, Health Care Bureau Chief. The Health Care Bureau is a part of the Social Justice Division, which is led by Alvin Bragg.

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