By Jill Buterbaugh, RN, MSN, CRNP, FNP-BC and Carle Garland, Billing Specialist
What is the difference between varicose veins that insurance covers and cosmetic veins that insurance will not pay for?
Venous insufficiency is a medical disease that causes varicose veins to develop. Varicose veins by definition are veins that have become dilated more than 5 mm. Once the vein becomes that dilated it loses its ability to recoil or retract back to its normal size. Similar to elastic that loses its stretch. The vein walls then lose their integrity and fluid and nutrients leak into the tissues and with time, result in physical symptoms. As the veins dilate, there are one way valves inside them that fail to close properly and this allows blood to flow in the wrong direction back down the vein further increasing the pressure in the vein and further dilating the vein. Insurance plans generally will pay for the treatment of varicose veins that are 5 mm and greater in size with more than one half a second of blood flowing in the wrong direction. This information is obtained by measuring veins by an ultrasound examination.
The initial physical examination and the ultrasound evaluation are generally covered by insurance because we are evaluating patients for medical conditions that have caused physical symptoms to occur that interfere with activities of daily living. The most common physical symptoms that result from varicose veins are pain, heaviness, aching, swelling and skin changes such as itching, dryness, rashes or wounds.
Cosmetic veins are those veins that are smaller than 3 mm and “spider” veins. Research has proven that these veins do not cause physical symptoms that are severe enough to interfere with activities of daily living. They may burn, sting or bleed but generally are not bad enough to cause complications. They are more of an annoyance. Those veins can be treated, but that treatment is not covered by your insurance and you would be responsible for the full payment. All cosmetic services are paid for at the time the service is received.
Spider Veins; What are the Insurance Policy Guidelines?
Each insurance company has guidelines that must be met in order for them to consider varicose vein procedures as meeting “Medical Necessity”. Medical Necessity is also referred to as having the procedures authorized or approved for payment.
Some of those policy guidelines specify that the patient must have tried rest, elevating the legs, and wearing medical grade compression for a 90-day period in order to alleviate their symptoms. We also must educate patients on weight management and the need for daily exercise. Also, insurance companies need to know if symptoms are present. Symptoms related to varicose veins would be pain, swelling, heaviness, aching of the legs plus skin changes such as itching, dryness, rashes, or wounds.
When our insurance department makes contact with your insurance to obtain medical necessity approval for your procedure, we must give them all of the above information. If the claim is approved, that does not necessarily mean you, the patient will not have any monies to pay. There are no “Hidden” cost with insurance plans but there are expenses that a patient is responsible for. Understanding those cost is extremely helpful. There is co-pay, deductible, and co-insurance. Let us try to explain each of these to you more in depth.
What is an insurance Co-Pay?
There are plan specific co-pay amount’s that are agreed upon by you and the insurance company that you are responsible for. Primary Care Physician co-pay and Specialist co-pay, which is what our office is classified as, can be different amounts. The co-pay comes into play for every visit in which you are seen and/or treated by either the physician, Dr. Faber or our nurse practitioner, Jill Buterbaugh. Co-Pay amount are always due at the time the service is received. No exemptions.
There may be instances that an insurance company will apply a co-pay amount to another service, such as a procedure, that we the office were not aware of and in that case the patient will be billed after the claim is processed through the insurance company.
What is a Deductible?
A deductible is a once per year amount that a patient is responsible for. The year time frame may vary in it’s began and end date so that is very important for a patient to know when that time starts and ends. It usually is larger amount but it is only calculated and paid once per year. Co-pay amounts do not count towards your deductibles.
What is a Co-Insurance?
The co-insurance is a percentage amount agreed on by the patient and the insurance company. An example would be and 80/20 co-insurance which means the insurance company pays 80% of their allowable amount per visit/procedure and the patient is responsible for the 20%.
Should our office write off any of the fees listed above, this could result in your insurance company terminating our contract with them. We, the physician’s office, have a written contact with these insurance companies and failure to follow the rules can result in our contract with them being terminated.
What kind of payment options are available?
All fees that are determined to be the patient’s responsibility with regards to insurance are due within 90 days of the date of service. We do accept Cash, Check, Master Card, Visa, and Discover. We also accept Care Credit which is a medical credit card with no financing charges for 6 months up to 1 year if paid in full during that time period. For questions on Care Credit, there web address is www.carecredit.com.
How do I find out what is covered by my Insurance?
There is usually a customer service number on the back of your insurance card you can call. If you still have questions we can help. Carle Garland is our billing specialist and can be reached at firstname.lastname@example.org or by calling (814) 515-9919 extension 304.