Changes to the Medicare Benefits Schedule (MBS) will directly affect rebates and health fund coverage for certain procedures. The following are some popular procedure that is impacted:
Medicare concerning breast surgery
The new Medicare changes that came into effect on November 1st, 2018 are going to have a profound impact on certain surgical procedures. These will effect among others, all breast operations where implants have been used even if the original surgery was many years before.
In the case of breast reduction, Medicare uses the description “… in the context of breast cancer or developmental abnormality of the breast”. However, there is no definition of what a developmental abnormality is.
Wikipedia states “A birth defect, also known as a congenital disorder, is a condition present at birth regardless of its cause. Birth defects may result in disabilities that may be physical, intellectual, or developmental. Developmental disability is a diverse group of chronic conditions that are due to mental or physical impairments that arise before adulthood.”
So, therefore, Medicare’s use of the term developmental abnormality is broad-based and open to interpretation. What is a physical impairment that arises before adulthood? The new breast reduction item number allows for a reduction if there is a pain but does not allow for the insertion of implants under any circumstance.
Regarding corrective surgery where implants have been used, the surgeon MUST take photographs of the breasts before the implants have been removed, then commence the operation, remove 1 of the implants, take a second photograph of the breast with the implant removed to demonstrate “ …unacceptable deformity “ if the surgeon was to NOT replace the implants.
This practice is either going to require another member of the surgery team taking the photos, or the surgeon will need to “unscrub” take the photos and then re-scrub to continue the surgery.
These practices do not constitute best practice and will increase the amount of time for the operation. Further, the possibility now arises where Medicare might audit a particular surgeons practice to ensure compliance.
Therefore, there may be a situation where Medicare deems that the replacement of the implants was NOT to prevent an unacceptable deformity and even after the surgery, may then say the operation was cosmetic and reverse the ability to claim. As this is new territory, we have no idea whether this is going to be a real situation or not.
Also as of November 1st, a breast reduction that is not a developmental abnormality or related to breast cancer but is for large breasted women with pain, implants cannot be used under any circumstance. Also, with regards to a breast lift, the only time a breast lift operation is not cosmetic is if your youngest child is 1 yr old or older and not more than 7. If you have never had children or your youngest child is older than 7, a breast lift is ALWAYS cosmetic and so you cannot claim.
Summary regarding implants in breast surgery
1. Corrective surgery for complications with new implants is covered if the replacement implants are not bigger than the originals. Bigger implants = breast enlargement = cosmetic surgery.
2. Breast reductions cannot be performed with implants. Implants = cosmetic surgery so you cannot claim.
3. Breast lift (with or without implants) can be claimed for if your youngest child is between the age of 1 and 7. This operation is cosmetic surgery if you have never had children or your youngest child is older than 7.
Medicare concerning abdomen procedures
Regarding tummy tuck and related “body lift” operations, other new Medicare rules apply. The 2 situations here relate to weight loss either diet and exercise, or after gastric sleeve or lap band surgery to name 2. In this situation, the weight loss must be at least 5 BMI units.
Regarding pregnancy and weight loss, the maximum weight AFTER the birth of the baby is used in the BMI calculation so, the weight of the baby is deducted from the maximum pregnant weight to calculate the 5 BMI units.
The difficulty arises where there has been significant skin laxity with or without muscle separation. In this situation, Medicare states that this will be viewed as a cosmetic operation and therefore it will not be possible to claim.
Medicare concerning labiaplasty procedures
For this operation to be non-cosmetic, Medicare states that the surgery is necessary “… for a structural abnormality that is causing significant functional impairment, if the patient’s labium extends more than 8cm below the vaginal Introits (opening) while the patient is in a standing resting position.”
This means the surgeon will have to stand the patient up with legs slightly apart and then actually measure the length of the labia from the opening to the point of maximum length. `This measurement, therefore, is taken from the inner aspect of the vaginal opening.
Dr. Goldman believes this to be highly inappropriate, degrading and totally unnecessary, however, this has been determined by “the government” and is now an absolute Medicare requirement in order to satisfy Medicare that the surgery in question is NOT cosmetic.
A further requirement is a detailed clinical history outlining the structural abnormality and the medical need for surgery of the vulva and/or labia must be included in patient notes, as this may be subject to audit. In other words, the opinion of a specialist is not sufficient and your medical information can be called for by Medicare to verify that the surgery was indeed medically necessary and not cosmetic.
This then opens up the possibility that the original decision can be reversed and that Medicare can after the surgery has been performed deem your operation to be cosmetic and not medically necessary and then potentially make you liable to “pay back” any funds that have been paid out on your behalf.
From Dr. Robert Goldman
Disclaimer: The following are the views and opinions of Dr. Robert Goldman and his alone. This does not represent views of organisations, government agencies, medical professionals, other groups or individuals.
What has happened now is that Medicare is attempting to redefine what constitutes a cosmetic operation versus what is not cosmetic and previously would have been medically indicated and necessary. The outcome is that Medicare and the healthcare system will be paying out less and you, the patient, will be paying out more.
With the new changes to Medicare, many more operations are now cosmetic and you cannot claim anything from your private health insurance as this is dependent on the new Medicare changes.
This opens up the whole issue of the usefulness and value of private health insurance as young fit people make more use of their private health insurance for these operations than operations for a significant illness.
It may be worthwhile considering dropping private health insurance and depositing the funds that you would have paid for your private insurance premium into your own superannuation fund, for example, and then use your superannuation fund through SuperCare as your own personal health insurance scheme.
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