When it comes to advanced wound care treatments, like skin substitutes (also referred to as amniotic grafts), are patients ever on the hook to pay for treatment out of pocket?
Like most examples across the healthcare industry, the answer is, “It depends.” But at Rebirth Advanced Healing, we’ve had enough experience to give you as clear and honest an answer as possible.
In most cases, patients don’t pay out of pocket for advanced wound care. At least not when Medicare coverage criteria are met and the right documentation is in place. That’s because Medicare Part B typically covers 80% of the allowable cost, and many of our patients have a secondary (Medigap) plan that pays the remaining balance.
Where things get tricky is when documentation is incomplete, when patients have Medicare Advantage or commercial insurance, or when insurers simply decide that skin substitutes are “not medically necessary.”
That’s where our team steps in.
We’ve helped hundreds of patients navigate this process, and we’ve seen how confusing and frustrating it can be when you’re trying to heal while also dealing with paperwork, insurance codes, and denials. So in this article, we break down exactly:
- How Medicare and Medicare Advantage cover advanced wound care
- Why some private insurers still deny skin substitute claims
- What patients can expect when it comes to out-of-pocket costs
- And how Rebirth’s team works behind the scenes to make sure you’re never blindsided by a bill
Medicare Part B: How Coverage Works
For most of our chronic wound patients, Medicare Part B is the primary coverage for advanced wound care treatments, including services delivered by our mobile clinical team and the use of skin substitute grafts (also called amniotic tissue or advanced biologics).
It’s important to note that coverage isn’t automatic. Medicare only pays for these treatments when they’re medically necessary and properly documented.
Here’s what that means:
- 28 days of conservative care first. Medicare requires at least four weeks of documented standard treatments, like dressing changes, compression, offloading, elevation, debridement, or wound vac therapy, before approving a graft.
- Wound must meet strict clinical criteria. It needs to be free of infection, with a healthy wound bed ready for grafting.
- Detailed documentation matters. Every treatment, measurement, and provider note must be included in the claim. Missing or incomplete documentation is the most common reason for Medicare denials.
When those boxes are all checked, Medicare typically covers 80% of the allowable cost, with the remaining 20% often handled by supplemental insurance.
Who Pays the Remaining 20%?
Even after Medicare covers 80%, the cost for these types of advanced wound care treatments can leave an expensive remaining balance on paper. The average size wound we treat (12 square centimeters in size) costs between $2,000 and $3,000 per treatment. A patient is allowed up to 10 total treatments over 12 weeks.
Many Medicare patients carry a secondary (Medigap) insurance that covers that remaining 20%, costing patients $0 out of pocket.
When you don’t have a supplemental plan, Rebirth takes a compassionate and transparent approach to billing.
We send two statements, 30 days apart, giving patients time to review and respond. We do not use a collection agency. Instead, our billing team works directly with each patient to arrange a payment plan or help them apply for financial hardship programs when needed.
You’ll always talk to a human being (never a third-party collector) and we’ll never surprise you with unexpected charges.
What About Medicare Advantage and Commercial Insurance Plans?
While most of our patients are on Medicare Part B and supplement coverage with secondary insurance, we still meet with patients who come to us with Medicare Advantage plans and private (commercial) insurance plans.
Even those Medicare Advantage Plans (Part C) are legally required to follow the same coverage rules as Original Medicare, in our experience, that’s not always what happens in practice. When it comes to skin substitutes, Medicare Advantage Plans have not covered that advanced treatment.
Similarly, private insurers, despite saying in their coverage documents that they do cover the use of skin substitutes for chronic wounds, often label them not medically necessary and deny coverage.
It’s unfortunate, because these grafts work.
Our team recently reported a 98% wound improvement rate among patients treated with advanced biologics. Those real-world results show how effective these therapies can be when properly used.
So what does this mean for the patient?
Well, for starters, it means they’ll never be surprised by a bill from us.
Rebirth runs every insurance plan before starting treatment and verifies coverage with both your insurer and our clinical team. If a claim is denied or not covered, we’ll let you know upfront before any treatment begins. We don’t move forward without your consent, and we’ll explain all options clearly, including appeal paths or financial assistance if needed.
In short: while it’s frustrating that some insurers still lag behind the science, you’ll always know exactly what’s covered and what isn’t, long before we start.
Know Someone Fighting a Chronic Wound?
If you know a patient, family member, or resident struggling with a wound that hasn’t improved after a month of standard care, it’s time to explore advanced options.
At Rebirth Advanced Healing, we make the process simple, verifying coverage, coordinating with referring providers, and bringing advanced biologic treatments directly to the patient’s home. With a 98% wound improvement rate, we’ve seen how quickly lives change once the right treatment begins.
Disclaimer: This blog is for general information only. It is not medical advice and does not determine or advise on benefits coverage. For medical concerns, talk to a healthcare provider. For benefits questions, contact the appropriate agency or your insurer.
