There has been no change to Medibank's policy in relation to plastic surgery and members with legitimate medical claims for these procedures as verified by their surgeon and hospital will be covered.
Medibank has always covered plastic surgery where it is for legitimate medical reasons and continues to do so. However we do not and will not cover cosmetic surgery that is purely for aesthetic purposes. This is supported by our fund rules, government regulations, and is clearly outlined in our guidelines.
As this area of surgery is unique and procedures such as eyelid surgery, breast augmentation and lipectomy can be performed for purely cosmetic or medical reasons it is essential that we have robust review process to ensure we are paying the correct claims on behalf of our members.
Medibank has acted to ensure that only legitimate claims are being paid, after uncovering a number of claims that could not be verified.
In a review earlier this year we found more than 800 cases over the previous three years where no medical diagnosis was provided in relation to these procedures and the hospital claims indicated that the procedures may be cosmetic. In over 25 per cent of these cases the hospitals either agreed that the procedures were cosmetic or they were not able to provide evidence of medical necessity. In a further 20 per cent of cases we are still waiting on information from hospitals about whether the procedures were medically necessary.
Subsequent to this a number of hospital operators requested that we confirm the eligibility of upcoming plastic surgery for our members to ensure it is for medical reasons. Therefore, we have created a template that hospitals can use at their discretion, but they are under no obligation to do so.
With any new process it takes some time to ensure that the system is error free. Any issues that arose in the inception of the new process have now been resolved and legitimate claims have been paid. We have contacted a small number of members affected by this and reassessed their claims.
If anyone believes they have an outstanding claim in error for a legitimate plastic surgery procedure, we urge them to come forward to have their case reassessed.