Most of our medical services are covered by insurance. We participate with the following insurance companies:
Beech Street/Capp Care
Anthem Blue Cross Blue Shield
Flagship Patient Advocates
Integrated Health Plan
National Provider Network, Inc.
One Health/Great West
Perfect Provider Network (PPN)
Private Healthcare Systems (PHCS)
Rocky Mountain Health Plans
San Louis Valley HMO
Sloans Lake Managed Care
South Metro Primary Care
Union Pacific Railroad
Insurance and Copayment
There is a fee for all new consultations. If you have insurance, we will bill your insurance and you will be responsible for your co-pay, co-insurance or deductible.
If you require an Ultrasound, there is an additional fee. If you have insurance, we will bill your insurance company for this service and you will be responsible for your co-pay, co-insurance or deductible.
For all cash pay, or non-covered services, we have a cash-pay discounted consultation fee. Please call the office at (303) 777-8346 for further information.
Dr. Norton participates with many insurance companies; please see the payment section for a full listing of participating insurance companies.
If you have a question about your insurance, please call our office at (303) 777-8346.
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 considered cosmetic, so it will not be covered by your insurance. In fact, most varicose vein surgeries are covered by health insurance.
There are steps that we must take to prove medical necessity to your insurance company. Dr. Norton performs an ultrasound of the leg to show the following:
- Venous Insufficiency
- Reflux in the Veins
- Vein Diameter measurements
Insurance Companies require the following criteria be met:
1. A trial of non-operative management has failed. Including:
- Avoidance of prolonged sitting or standing
- Frequent elevation of affected legs
- Use of compression therapy (length of time varies by insurance carrier)
2. Presence of One of the following
- a. Persistent symptoms interfering with activities of daily living despite non-surgical management and daily medication. This includes: Pain, aching, cramping, burning, itching and/or swelling during activity or after prolonged standing, severe enough to impair mobility.
- Recurrent episodes of superficial phlebitis
- Non-healing skin ulceration
- Bleeding from a varicosity
- Stasis dermatitis
- Refractory dependent edema
When you come in for consultation, Dr. Norton will provide a detailed treatment plan. After scheduling your appointment, we send documentation to your insurance company and request that they provide us with Pre-Authorization to treat you. 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 authorize the treatment, you still may have some out of pocket costs. These costs differ greatly with every plan.
Pre-Authorization vs Pre-Determination
Each insurance company is different. Some insurance companies require pre-authorization, while others require pre-determination. Definitions are listed below:
Pre-Authorization (also known as pre-notification or pre-certification) confirms that a physicians’ plan of treatment meets medical necessity criteria under the applicable health benefit plan. Medical documentation is submitted to the insurance company and is reviewed by a medical director. If approved, a pre-authorization number is given as reference.
A Predetermination of Benefits is a written request for verification of benefits prior to rendering services. Recommended when the service may be considered experimental, investigational or cosmetic. Many insurance companies do not require pre-authorization, but recommend a predetermination to verify that you meet medical criteria. Approvals and denials often are based on approved Medical Policies.
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. We make every effort to provide accurate information, however occasionally we are given incorrect information by your insurance company that causes our estimated figures to be incorrect. We always recommend that patients call their insurance company to verify the information we have received is correct. Keep in mind these are only estimates. Actual out of pocket costs are determined by the insurance company after the claim is processed.
Understanding your insurance coverage can be challenging. Below are some key terms that your insurance uses that we will clarify so that you can better understand your coverage and responsibilities through your insurance plan.
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, Aetna HMO plans and New West Physicians Group. Please check with your insurance to see if a referral is required.
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. All co-payments through Denver Vein Center will be considered a “specialist” visit. Your co-payment amounts are listed on your insurance card, and are due at the time you have your appointment.
Your deductible is the amount of expenses set forth by your insurance plan that you have to pay out of pocket before your insurance company pays the claim. Deductible amounts differ with every insurance plan. Please call your insurance if you are unsure of your deductible.
After you meet your deductible, most plans require you to pay a co-insurance. The co-insurance amount is a set amount they pay after your deductible has been applied. The insurance will pay a percentage and the rest is the patient balance. For example, if you have a 90/10 plan, your insurance will pay 90% of the claim after your deductible and you will be responsible for 10%.
Out of Pocket Maximum or Cost Sharing Cap
This is an amount the insurance company has set as your total out of your pocket costs 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 company covers claims at 100%, so you no longer have to pay co-insurance amounts.
In Network Benefits
Choosing an in-network provider lowers your out-of-pocket expenses. In-network providers and those who “participate” with your insurance have agreed to provide discounted fees for their services to members. Providers who “participate” with your insurance company will accept the insurance payment as payment in full. You are only responsible for your in-network deductible, co-insurance (if any) and the co-payments listed in your specific plan.
Out of Network Benefits
Many insurance companies offer out of network benefits for providers that do not participate in their plan. Usually the out of pocket costs are higher. Check with your insurance provider for more details.