Does Medicare Cover Gynaecomastia Surgery?
Does Medicare cover gynaecomastia surgery? Does private insurance cover male breast reduction? These are questions patients often ask Dr. Bernard Beldholm, a gynaecomastia surgeon in Australia. This article talks about how to qualify for Medicare rebates, rules, insurance coverage and how much gynaecomastia surgery costs.
What is Medicare?
Medicare is Australia’s universal health system.
What does Medicare cover?
It covers cosmetic surgery procedures that are deemed medically necessary. Procedures that are done for aesthetic reasons do not qualify. When a procedure is classified as medically necessary, a Medicare item number is assigned to it. This is listed in the Medicare Benefits Schedule (MBS). If your surgery has an item number and you meet certain criteria, you can receive a partial rebate for surgery. There are plenty of exclusions, so keep reading.
How do I claim a Medicare rebate?
Some cosmetic reconstructive procedures qualify for a rebate. To claim a rebate, a GP must refer you to a specialist surgeon. The surgeon determines whether your procedure is medically necessary or cosmetic. If it is medically necessary, then this is what happens next. You’ll have the surgery. After the surgery, you will receive a bill. You’ll pay the bill, then submit the bill as a claim to your health fund in order to receive a partial rebate.
Does Medicare cover gynaecomastia surgery?
The gynaecomastia operation is not done in the public health system. It is done in the private system. Medicare does not pay for private hospitals, as this is considered an out-of-pocket expense. Private health insurance may cover this cost if a Medicare item number applies to your surgery AND you have the right level of cover. The amount you get back varies from health fund to health fund.
What is the item number for gynaecomastia?
There is an MBS item number for gynaecomastia surgery if it is deemed medically necessary or reconstructive. The item number for gynaecomastia surgery is 31525: “Breast subcutaneous mastectomy for gynaecomastia”.
What are the rules for using MBS Item 31525 for gynaecomastia?
The surgery must be medically necessary or reconstructive in nature. You must have a history of chronic pain and/or a breast gland of significant size. Your specialist surgeon must verify all this. You have to have top cover. You must have gynaecomastia for 12+ months. The surgery must take place in an accredited hospital. If a surgeon offers liposuction-based gynaecomastia surgery in a private facility (i.e. not a hospital), you cannot claim the item number. Other exclusions may apply.
Does insurance cover gynaecomastia surgery?
If you have a private health plan, it may reimburse you for some or all of the hospital fees, depending on your level of coverage. The surgeon fee is an out-of-pocket expense.
When will you receive the rebate?
A rebate means you have to pay the fees out-of-pocket first. You’ll be provided with a receipt upon paying the surgery bill. If you qualify for the gynaecomastia item number, you can submit a claim to your health fund. Assuming you meet all the qualifications above, you’ll receive a portion of the surgery cost back as a rebate. The full cost of surgery is not reimbursed. Usually, it is just the hospital stay and anaesthetist fees that you’ll get back. Again, this varies based on the health fund.
How much does gynaecomastia surgery cost in Australia?
The average cost of gynaecomastia surgery ranges from $3,000 to $6,000 AUD. This may include the surgeon fee, hospital fees, anaesthesiologist and other items.
If you have top-level hospital coverage, hospital fees may be covered fully. That is the best case scenario. Without health insurance, you’ll pay for hospital fees out of pocket. This costs approximately $2,000 to $4,000 on average.
Each day in the hospital adds to the cost. Most patients go home from surgery the same day. Gynaecomastia surgery takes just two hours, plus time in the recovery room as you wake from anaesthesia. While most patients go home shortly afterward, an overnight hospital stay is possible. If you have a longer hospital stay due to complications, which are thankfully rare, that may be covered if you have top-level hospital coverage.
An anaesthesiologist is a doctor that administers sedative drugs before surgery. Sedation is necessary so there is no pain during the procedure. You will be fully sedated with general anesthesia during your gynaecomastia surgery. There will be no memory or sensation of the procedure. You will wake up in a recovery room with a flatter chest.
Anaesthesiologists also monitor your vitals during surgery. They check your breathing and heart rate while you are in the O.R. This allows your surgeon to focus on sculpting your chest. Anaesthetists go through many years of medical training. Their job is very important. They ensure you are safe from the moment you go under sedation to when you wake up.
Like surgeons, anaesthetist fees vary. Some charge more than others. Pricing varies based on years of experience, training and geographic location.
The surgeon fee usually varies based on years of experience. That means a more skilled surgeon is likely to cost the most. In general, higher prices reflect more service and, theoretically, better results for patients.
The surgeon cost also depends on the type of surgery you need. There are two kinds of gynaecomastia surgery:
Gynaecomastia surgery with breast gland removal
In men with true gynaecomastia, the breast gland is faulty. An overactive gland makes breasts grow more than they should. The gynaecomastia treatment in this case is surgical removal of the gland. Breast liposuction may be done to reduce male breasts as well.
Male breast reduction without gland removal
Some men don’t have true gynaecomastia. Instead, they have what is known as pseudo-gynaecomastia. That means they have male breast enlargement that looks similar to gynaecomastia, but there is nothing wrong with the breast gland itself. Genetics, body fat distribution and being overweight are common causes.
Male breast reduction is done to reduce fat and reshape a normal, flat chest in men with pseudo-gynaecomastia. The gland is not removed, since there is nothing wrong with it. Since the gland stays intact, the procedure is less invasive. Thus, it may cost less than a full gynaecomastia surgery with gland removal. Since the surgery is done for cosmetic reasons, the health fund rebate is not applicable.
How much does Dr. Beldholm charge for gynaecomastia surgery?
A lot of Australia gynaecomastia won’t reveal prices online or by phone. Dr. Bernard Beldholm believes in transparent pricing. This allows his patients to plan for the cost of surgery. His current gynaecomastia pricing can be found on this page.
What does Dr. Beldholm’s surgeon fee include?
- Surgical fee for Dr. Beldholm
- Two (2) compression garments
- Six (6) post-op appointments
- Six (6) LED light treatments
What is not included?
Dr. Beldholm’s fee just represents the surgeon fee and related items listed above. The hospital fee and anaesthetist fee are separate charges. Those fees are billed separately.
Why do some surgeons hide gynaecomastia pricing?
Most surgeons avoid quoting gynaecomastia prices online or over the phone. There is a good reason for this, but also some not-so-great reasons.
Why must you book a consultation to find out the price?
Many surgeons want you to come in for a consultation to obtain pricing. This is perfectly reasonable, since not all gynaecomastia surgeries are the same. Some men have breast enlargement, a faulty breast gland and/or loose skin. Other men just want to reduce chest fat, but the gland is fine. Therefore, different surgical approaches may be used to address the patient’s desired cosmetic outcome.
Some male chest reduction procedures are more extensive than others. Gynaecomastia surgery is tailored to your needs. The final cost may differ based on the treatment plan you and your surgeon agree upon.
Do surgeons that hide prices have bad motives?
Not necessarily. As mentioned, your treatment plan is unique. The type of gynaecomastia surgery you need may affect the final price you’ll pay. Most surgeons want to see you in person so they can examine the chest. From there, they develop a surgical plan and provide you with an accurate price.
Since most men that see Doctor Bernard need gynaecomastia surgery with lipo and breast gland removal, his current surgery fee reflects this.
But some surgeons are up to no good…
Most surgeons want to see you in person first so they can give you an accurate price quote. However, some surgeons hide prices for less noble reasons. Some charge high fees and they don’t want to scare customers away by posting it online. If they can just get you in the door for a consultation, they have got you to invest your time. It’s easier to rationalize paying the surgeon fee when you’ve sacrificed your time. And if they are a very convincing salesman, you might say yes to surgery — even if you can’t afford the surgeon fee. While most doctors aren’t hiding prices for malicious reasons, it still happens.
How can I tell if a surgeon is hiding prices for good or evil?
Most surgeons don’t list prices online. That is pretty standard. Many surgeons won’t quote prices over the phone either. But if a surgeon won’t provide a general price range, that’s a red flag.
They should be able to give you a rough estimate of the prices they charge. For example, they could say, “My average price range for gynaecomastia surgery is $4,000 to $6,000”. Another surgeon might say, “My surgeon fee is $6,000+”. It’s up to you to decide if the surgeon’s skills and qualifications warrant the price they charge. If they cannot provide a general price range over the phone, you’ll have to come in for a consultation to get a quote.
Doctor Bernard is honest about pricing
Doctor Bernard knows it is frustrating to shop around. What is the point of seeing a surgeon if you know you can’t afford it? That is why he believes in transparent pricing. His surgical fee is listed right on his website.
The perils of bargain hunting for a surgeon
Admittedly, price shopping is not a good way to find the best gynaecomastia surgeon in Australia. The right surgeon for you is the one you feel most comfortable with — a doctor you trust because they are compassionate, a good listener, licensed and highly skilled in the type of surgery you need.
Get help paying for gynaecomastia surgery
Not all cosmetic surgery patients qualify for health fund rebates or insurance coverage. However, the cost of surgery is made affordable in other ways. Payment plans and special financing are accepted by Dr. Beldholm. Click here to learn more about payment plans.
Learn more about Australia Medicare rebates for cosmetic surgery
Dr. Beldholm is a body contouring surgeon in Australia that helps men and women improve their bodies so they can look great in clothes. While not all patients are eligible for health fund rebates for cosmetic surgery, it’s possible if the surgery is deemed medically necessary. Book a private consultation for more information.