Patients living with painful swelling form venous reflux disease, or varicose veins, know all too well that the condition is more than just a cosmetic issue. Varicose veins can lead to swelling of the lower limbs, skin inflammations and leg ulcers. Venous reflux symptoms are progressive and will worsen over time, if left untreated. Unfortunately, many health insurers see this condition differently. There are approximately 25 million patients with varicose veins in this country, and this is an overwhelming financial liability to insurance companies. The insurance companies have required strict pre authorization criterion and limited the veins treated to the Great Saphenous and the Small Saphenous vein reflux and will not cover cosmetic venous issues or venous problems that fall out of the common distribution patterns.
Advanced Laser Vein Care is a free standing private practice that is dedicated to your care. If you choose to directly pay for your services (fee for service) there are no restrictions or limitations, other than your own health care status, and you can be scheduled directly for your procedure at the time of your initial consultation. For endovenous ablation procedures Medicalfinancing.com has been very useful for our patients. Of course we also help you get the most out of your insurance plan within the framework of your benefits. Please address any further concerns to our Patient Care Coordinator, Valerie Galvez.
HMO and PPO
Advanced laser vein care, as a common courtesy for all of our patients, will accept your insurance payments in full regardless of whether we are in or not in your provider network.
Medically necessary. Most insurance companies have set up strict criterion to determine if vein treatment is to be considered "medically necessary." This may include one or more of the following:
- Lifestyle Disruption: the daily activities of the patient must be disrupted significantly.
- Pain: The patient must be experiencing pain as a result of their vein disorder.
- Failure of Conservative Measures: Other methods of treatment, including exercise, weight loss, regular periods of leg elevation, pain relief with anti-inflammatory medications (NSAID’S), and a 6 month trial of compression hose, have been tried and failed to provide adequate relief.
- Vein Size: Bulging veins larger than 4 mm are often considered medically significant.
- Complications: Complications, such as phlebitis, bleeding veins, leg swelling and leg ulceration make it more likely an insurance company will consider treatment medically necessary.
Conservative measures yield only temporary benefits and do not address the underlying cause of the problem which is venous valve failure: reflux. As soon as you stop wearing compression stockings, your symptoms will immediately return. Prolonged reliance and delay of definitive treatment may only necessitate more extensive procedures and ultimately are not beneficial to the patients or the insurance companies. However, in order to maintain our excellent status with the insurance companies, we will gladly comply with their policies.
Pre-existing exclusion Many insurance companies also have a pre-existing exclusion clause. Typically, these policies will not cover a condition which has been seen by another physician within 6 months prior to initiating coverage with the insurance company. They may require that you pay benefits for a minimum of 11 months before they approve coverage.
Out Of Pocket Expenses: Deductibles, Co-Insurance and Co-payments
Although you may be paying a considerably monthly premium for your health insurance (or a percent of what your employer pays), your health plan most likely does not cover 100% of the cost of your healthcare. Additional costs (or out-of-pocket expenses) that you may be responsible for include an annual deductible, copayments, and co-insurance.
A deductible feeisthe amount you have agreed upon with your insurance company that you must pay out of pocket before your insurance pays for the remainder of your authorized services. If you have not met your deductible, this is due before services can be rendered. The amount is paid directly to your physician and your insurance company will be notified of this amount when the physician’s bill has been submitted.
Insurance companies typically negotiate with physicians to only pay a percentage of the prevailing customary and reasonable fee and this may vary from 50 to 100 % of the physician’s normal charges. The gap between the physician’s customary and reasonable fees and the amount that the insurance company has negotiated with the physician is an amount that is called the co-insurance. In other words, Coinsurance is a percent of the cost of your care. For example, if a doctor's visit is $100 and you have a 20% coinsurance, you will pay the doctor $20 and your health plan will pay the doctor $80 after the Deductible has been met. Coinsurance is often used when you get services from an out-of-network provider in a PPO.
A copayment (orcopay) is a fixed-dollar amount that you pay each time for certain services. Most commonly, you will be responsible for a copayment each time you have a doctor's visit and for each prescription medication you fill. For example typical copayments may be $20 for each primary care physician visit, $35 copayment for a specialist visit, and $20 for each brand-name prescription. Copayments are most often used in HMOs and for services you receive from a network provider in a PPO.
Please check your benefits with your insurance company.
HMO Insurance HMO’s, including Kaiser, will only cover treatment that is provided by their own contract physicians, and only provide services at their own contracted facilities. It may be more cost effective for an HMO to offer conservative medical care and conventional surgical options (stripping and ligation) and exclude advanced services such as endovenous ablation techniques, ultrasound guided foam sclerotherapy and Microphlebectomy. We are not contracted with any HMO plan, including Medicare HMO’s, but we can see on fee for service basis and provide the full array of techniques that we use to treat problems often not covered by HMO plans.
PPO Insurance Advanced Laser Vein Care is in network with Blue Cross and Aetna and will accept any other PPO insurance as long as you have out of network benefits and agree to your Coinsurance requirements.
MEDICARE, MEDICARE HMO and MEDICARE PPO
Medicare reimburses vein specialists after documentation of venous insufficiency by ultrasound. for "medically necessary care" but not for "cosmetic care". Medically necessary signs and symptoms include pain, swelling, ulceration and spontaneous bleeding. In these cases Medicare will not require preauthorization for approval of your endovenous ablation and ambulatory phlebectomy procedures. A word of caution, if you chose a Medicare HMO supplement plan you are usually limited to the same restrictions described above and we do not participate in any HMO plans.
If you need help to determine whether your insurance provides benefits for you please call our Patient Care Coordinator, Valerie Galvez, at 909 948 5272.