Is Mohs Surgery Covered by Insurance?

Mohs surgery is a specialized, precise surgical technique used to treat common types of skin cancer. This procedure involves removing cancerous tissue layer by layer and immediately examining each layer under a microscope until only cancer-free tissue remains. Understanding insurance coverage for Mohs surgery is a common concern for many individuals. This article guides individuals through insurance coverage for Mohs surgery, clarifying financial responsibilities and options.

Understanding Coverage Basics

Health insurance coverage for medical procedures like Mohs surgery depends on the procedure being medically necessary. Insurers typically classify Mohs surgery as medically necessary for certain skin cancers, such as basal cell carcinoma and squamous cell carcinoma. This medical necessity determination establishes the basis for an insurer’s willingness to cover treatment costs.

Individuals should understand key terms that define their financial responsibility within an insurance plan. A deductible is the amount an insured individual pays out-of-pocket for covered services before their insurance plan begins to pay. After the deductible is met, a copayment is a fixed amount paid for a covered service, while coinsurance is a percentage of the cost of a covered service paid after meeting the deductible.

The out-of-pocket maximum is the most an individual will pay for covered services in a policy year. Once this limit is reached, the insurance company typically pays 100% of costs for covered benefits for the remainder of the policy year. Health Maintenance Organizations (HMOs) and Preferred Provider Organizations (PPOs) approach specialist visits and network coverage differently. HMOs usually require a primary care physician referral and generally only cover in-network care. PPOs offer more flexibility, allowing individuals to see specialists without a referral and providing some coverage for out-of-network providers, often at a higher cost.

Navigating Your Specific Policy

To determine coverage for Mohs surgery, individuals should review their health insurance policy documents. These documents, often available through an online member portal or as a physical member handbook, contain the terms and conditions of coverage. Locate sections pertaining to surgical procedures, dermatological care, and specialist visits.

Look for specific details regarding coverage limitations, exclusions, and requirements for referrals or pre-authorization. Understanding whether Mohs surgery is a covered benefit and under what circumstances is crucial. This review helps identify potential out-of-pocket expenses based on the plan’s deductible, copayment, and coinsurance structure.

Contacting the insurance provider directly offers accurate information regarding coverage. When communicating, ask specific questions, such as whether Mohs surgery requires pre-authorization or a referral from a primary care physician. Inquire about in-network requirements for dermatologists or surgeons to ensure the chosen provider is covered at the highest benefit level. Ask for an estimate of out-of-pocket costs based on your deductible, copayment, and coinsurance. Requesting written confirmation of coverage or pre-authorization provides a valuable record.

Financial Considerations and Appeals

Even with insurance, individuals may incur out-of-pocket costs for Mohs surgery. Work closely with the Mohs surgeon’s billing department to obtain a realistic cost estimate. This estimate typically considers your remaining deductible, coinsurance percentage, and any applicable copayments. Understanding these potential expenses prior to the procedure allows for better financial planning.

After receiving medical services, an Explanation of Benefits (EOB) document will be sent by the insurer. The EOB is not a bill but a statement detailing how the insurance company processed a claim, showing total charges, the amount covered by insurance, and the amount for which the patient is responsible. Review the EOB against services received and estimated costs to ensure accuracy and identify discrepancies.

If coverage for Mohs surgery is denied, individuals have the right to appeal. The appeal process involves gathering necessary documentation, such as medical records, letters of medical necessity from the treating physician, and pre-authorization approvals. Follow the insurer’s internal appeal procedures. If the internal appeal is unsuccessful, an external review by an independent third party may be an option.

To manage out-of-pocket costs, explore financial assistance options. Many medical providers offer payment plans, allowing patients to pay their balance over several months. Some organizations or foundations provide financial assistance programs for cancer treatments or high medical bills. These resources can help alleviate the financial burden associated with necessary medical procedures.