Insurance Overview

One of the most frustrating aspects of healthcare, for patients and doctors, is dealing with insurance companies. This is especially true when it comes to vein disease. It is often thought that treatment for vein disease is always considered cosmetic, so it will not be covered by your insurance. In fact, more than 80% of what we do at VCI is covered by health insurance. Before we can ask your insurance for approval for your treatments, we have to prove that you have a medical problem that is causing you symptoms and can be treated. To prove this, we do an ultrasound of the veins in your legs to see whether or not they are working correctly. If the veins in your legs are not working correctly, you may have a disease called Venous Insufficiency, which we can treat, and when treated will improve your symptoms. After proving that you have a problem we can fix, and documenting the problem and your symptoms, we send that documentation to your insurance company and request that they provide us with Pre-Authorization to treat you. Before your
insurance company will approve your treatment, they usually want you to try some things on your own, like wearingcompression stockings and taking over the counter pain medicines like Advil, Aleve or Ibuprofen. These requirements vary with each insurance plan, but we will be happy to help you learn what your plan requires.
Once we receive approval from your insurance company for your treatment, we will put together an estimate of your out of pocket costs. Even if your insurance company agrees that your treatment is medically necessary and they will cover the treatment, you still may have some out of pocket costs. These costs differ greatly with every plan. Sometimes your out of pocket cost is just your specialist office visit copayment. Sometimes your out of pocket cost is a combination of your deductible and co-insurance amount. Before we schedule you for your treatment, we will make sure that you understand what your out of pocket costs will be, and arrange for you to pay them if necessary.

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Out of Pocket Costs

Your out of pocket costs are based on your contract with your insurance company. These costs can vary depending on what types of services you are receiving, whether or not you are seeing an in-network provider, and where you are receiving services. Prior to having any treatment at VCI, we will contact your insurance company and find out what your estimated out of pocket costs will be. This is a service we are happy to provide our patients, as we don't want there to be any surprises for you. However, occasionally we are given incorrect information by your insurance company that causes our estimated figures to be incorrect. We will provide you with a copy of the form we use to obtain your out of pocket cost information. This form (below) will contain all the information you would need if you want to call your insurance company to varify the information we were given. Download Out of Pocket Costs Form

Insurance Plans We Accept

Vocabulary

Getting your insurance to approve your procedure is half the battle. Understanding your coverage is the other half of the battle. There is nothing more frustrating that receiving information from your insurance that you don’t understand. There are some key terms that your insurance uses, that can be confusing. We will try to explain some of those terms for you now, so that you can better understand your coverage and responsibilities through your insurance plan.

Referral

A referral is an authorization from your insurance company for you to see a specialist. A referral has to be requested by your primary care doctor and submitted to your insurance company. Referrals are not always required for you to see a specialist, it depends on your insurance plan. Some major insurance plans that require referrals are Secure Horizons, Cigna HMO plans and Aetna HMO plans.

Co-Payment

A copayment is an amount that your insurance has assigned you to pay when you have a medical appointment. The amount of your co-payment may be different depending on what kind of appointment you have. Your co-payment at your primary care doctor may be different than your co-payment at a specialist’s office. Your co-payment amounts are listed on your insurance card, and are due at the time you have your appointment.

Deductible

Your deductible is the amount of money that you have to pay out of pocket before your insurance will start to pay. Deductible amounts are different with every insurance plan. Also, some types of appointments don’t apply to your deductible, meaning that you don’t have to meet your deductible before your insurance will pay for them.

Co-insurance

Even after you meet your deductible some plans require you to pay a co-insurance. The co-insurance amount is usually a percentage that your insurance company requires you to pay for every claim that they pay on. For example, if you have a 10% co-insurance, and your insurance company gets a claim for $100.00, they will pay $90.00 and you will pay $10.00.

Out of Pocket Maximum or Cost Sharing Cap

This is the maximum amount of money you have to pay out of your pocket per year. This amount does not usually include your deductible or co-payments, but does include your co-insurance payments. After you reach your out of pocket maximum, your insurance covers you claims at 100%, so you no longer have to pay co-insurance amounts.

In Network Benefits

Your insurance company makes contracts with doctors and facilities to provide care at lower costs. If you see a doctor, or go to a facility that has a contract with your insurance, you are going to an in network provider. This means that your costs are reduced because your insurance company’s costs are reduced. It is in your best interest to go to an in network provider. Either your insurance company or the provider you want to see can let you know whether or not they are in your insurance company’s network.

Out of Network Benefits

Some insurance plans do not offer out of network benefits, so you will want to check with your insurance company before you go to a provider that is not contracted with your insurance. If your insurance does provide out of network benefits, you will usually end up having more out of pocket costs because out of network benefits usually have a higher deductible and higher co-insurance amounts.