INSURANCE OBSTACLES TO TREATMENT BAFFLE PATIENTS SUFFERING FROM VENOUS REFLUX
“My veins are covered by insurance, right? But, the XYZ Insurance Co. representative said my varicose veins are a covered benefit on my insurance plan.”
By James White, MD
How many times have these words been uttered by potential patients upon arrival to our vein clinics? Yet, the majority of our patients have no earthly idea what is covered by their individual insurance plan or even what those words “benefits” and “medical necessity” even mean.
We, as providers, are all aware of the criteria for medical necessity regarding insurance coverage for therapeutic options in the treatment of venous reflux. Seems that we, as providers, follow the rules: Use documentation and evidence-based peer-reviewed studies to form our treatment plan decisions.
Despite our best efforts to offer therapeutic options to our patients for venous reflux, several obstacles must be addressed before proceeding with treatment. Even though the patient meets criteria for medical necessity, multiple financial constraints circumvent “medical necessity.” None of these obstacles have any bearing on medical treatment, just financial constraints. Yet, they have a profound impact on availability of care to our patients.
` Some of the obstacles include:
- Outrageous deductibles.
- Family out of pocket expenses.
- Plan limitations.
- Procedures MUST be completed in a designated time period, if not completed, formal evaluation must start over from day one with a baseline review.
- Request for independent patient evaluation by a primary care gate keeper prior to predetermination.
- Great Saphenous and Small Saphenous veins MUST be addressed and treated during a single therapeutic procedure.
- Policy riders to exclude future treatment options for varicose veins and venous reflux.
The list is every growing and complex.
How can we stop the madness? Unfortunately, at this point, we can’t. But we can offer assistance to our patients to enable them to navigate the complex maze of insurance coverage and financial constraints.
Let’s look at some options and plan strategies.
- Outrageous deductibles
- Family out of pocket expenses
Often patients and providers do not fully understand the deductible requirements imposed by specific insurance plans. These requirements are NOT universal. Requirements for coverage are as varied as collateral branches of the great saphenous vein.
With most plans, patients are required to meet deductible and out of pocket expenses for their individual coverage as defined by their individual insurance plan. Then payment for the procedures can be covered. This may be coverage at 100 percent or not, depending on each individual plan.
In a proactive attempt to help each patient, our office staff completes a query to the insurance provider prior to the patient’s baseline office visit. This information is then discussed with the patient from the initial presentation. This has nothing to do with medical care; but is offered as a courtesy to our patients.
Some plans offer different payment schemes depending on whether the procedures are completed in an office setting or a hospital setting. Some plans have different co-pays based on the provider status, specialists vs. non-specialist. Confusing? You bet it is confusing.
Out of pocket expenses have steadily increased over the last 15 years. In 2005, the average out of pocket expense for patients in our region averaged less than $800 for endovenous ablation of bilateral great and small saphneous veins. Today, our patients routinely expect to have out of pocket expenses in excess of $5,000 per year for similar endovenous ablation procedures.
There are in-house financing options and cash payment options.
Some patients may choose to complete the endovenous ablation procedures on a cash payment basis; as they are aware that their individual deductible is very high and that none of their annual deductible has been accrued. This is easy and basic.
We now have control over the patient-provider relationship and can set the fee for service. However, this places the payment burden on the patient without benefit of payment going toward deductible amounts.
Some of the options for self-pay include: Flex Health Savings Accounts-Flexible spending accounts (FSA) and health savings accounts (HSA).
FSA and HSA are both great healthcare plans that reduce an employee’s income tax liability and allow them to pay for medically-related expenses with pre-tax dollars. Many businesses offer HSA and FSA to their employees as a benefit in lieu of more comprehensive medical insurance plans.
You can also offer healthcare financing credit options such as Care Credit and Prosper Health Care Lending.
Prosper Healthcare Lending provides patients with several different options for financing that best suit their individual needs-different terms, interest rates, and monthly payment amounts. Prosper Healthcare Lending performs a “soft credit” check that will not affect the patient’s credit score. If patients choose Prosper, the funds are sent directly to the patient and the patient then pays the office as a cash pay basis fee for service. The office does not incur any fees for the Prosper Healthcare Lending, but patients must make loans greater than $2,000 to be eligible to use Prosper Healthcare Lending.
Care Credit offers several zero percent interest options to patients for 6- to 12-month time periods. The office is charged a fee for the patient to use Care Credit. Thus, the zero percent credit to the patient is covered by the office-related fees for service. But a word of caution: Counsel your patient in regard to high interest rates that will be imposed if the amount financed exceeds the initial time period for repayment.
Help your patient and family navigate the deductible maze
If approaching the end of the deductible year, it may be prudent for the patient to wait until the following deductible year in order to reduce out of pocket expenses. In other words, it would not be prudent to have one endovenous ablation procedure completed in December and have the contralateral limb treated in January encompassing two deductible calendar years. It would be better for this patient to wait and have both endovenous ablation procedures completed in the same calendar year.
Varicose veins and venous reflux disease are chronic problems, often times not urgent or emergent. Insurance providers understand this and are not compelled to make it easy for the patient to proceed with endovenous ablation nor do they provide patient advocate assistance. They are more than happy to accept double deductible payment for the endovenous procedures.
3) Plan limitations
Many of our patients work for large corporations that offer benefit insurance coverage to their employees. Insurance coverage plans are bid each year. Often the insurance plan offered goes to the lowest bidder. To be competitive, insurance providers add restrictions and limitations in the fine print.
One treatment per limb per lifetime
Cap limitations $5,000 per lifetime for varicose vein treatments
Our office provides patient with peer review data regarding the need to treat all sources of venous reflux. Armed with that information, we recommend that the patient contact human resources at their place of employment. We recommend that they, the patient, file a complaint and educate other employees as to the limitations imposed by their current insurance plan.
We encourage the patient to explore options for plan changes in conjunction with human resources and employee management. Often, human resource personnel take into consideration requests from employees regarding future insurance coverage options.
4) Procedures MUST be completed in a designated time; if not completed,
formal evaluation must start over from day one with a baseline review.
Educate patients in regard to time limitations imposed by their insurance plans. Place patients on an update list with imposed time limits. This list needs to be reviewed on a regular interval. Dedicate staff to request time extensions to avoid start over from day one with a baseline review.
And the newest ploys:
5) Request for independent patient evaluation
by a primary care gatekeeper prior to predetermination
Contact insurance medical director and request name and qualifications of the primary care gatekeeper who is mandated to complete the independent review. Speak with the primary gatekeeper as a peer-to-peer.
6) Great saphenous and small saphenous veins MUST be addressed
and treated during a single therapeutic procedure.
Be aware that you can request a peer-to-peer review to speak with a physician peer in order to discuss complex patient cases. Your insurance clerk can request a peer review and set a date and time for the phone call.
If all tactics fail, you may contact the insurance medical director to discuss the individual case as a peer-to-peer review. The majority of the time, denials are overturned by the medical director based on pertinent data that was not understood by the initial non peer reviewer.
7) Policy riders to exclude future treatment options
for varicose veins and venous reflux.
Educate the patient regarding their options to change insurance coverage. Many patients do not realize that they have negotiating power to request plan changes for coverage. Many patients have not even thought of other insurance plan opportunities.
Our office can provide patients with names and numbers of people who specialize as insurance brokers. They are not insurance sales people, but true insurance plan brokers who can analyze and make multiple insurance plan offers to patients who currently have problems with policy rider limitations.
Don’t forget the patient who is near Medicare coverage age. Often, these patients can be treated with conservative measures to get them to the age of Medicare coverage with less out of pocket burden for the patient.
We recently had a patient who was 64 years of age. In order to complete endovenous ablation for her C4 venous stasis disease, she would have been required to pay $5,000 in out-of-pocket expenses. We continue to manage her venous reflux disease with conservative measures. If those measures fail, she will incur less out of pocket expense in the future with Medicare coverage for endovenous ablation procedures.
It is a sad day indeed that we as providers must tailor recommendations for treatment based on financial constraints and not purely on medical necessity. But, that is the day and age in which we live.
Please understand that this article is in no way comprehensive; but just an introduction and platform to build upon to help your patients navigate the insurance maze regarding benefits and options. Believe me, the maze will change and new obstacles regarding treatment reimbursements are sure to come in the near future.
“Ms. Smith, it is possible that your varicose vein treatments are covered by insurance . . .the accountant will see you now.”
James E. White, MD, FACS, who is board certified in general surgery, phlebology and cosmetic surgery, owns Advanced Surgical Concepts, in Chattanooga, Tenn., a practice in phlebology and cosmetic surgery. He was graduated Magna Cum Laude from the Medical College of Georgia in 1990. He then completed a General surgery residency at the University of Tennessee, Chattanooga in 1996. He is a Diplomat with the American Board of Phlebology and the American Academy of Cosmetic Surgery.