by Marlin Shul, MD, MBA, RVT, FACPh
The healthcare reform climate is definitively upon us and commercial carriers are dodging and shifting to limit utilization of phlebology procedures. The administrative burden of the medical vein practice has never been threatening. If the heterogeneity of medical necessity polices and coverage guidelines were not enough, the frequency for which they change could make one dizzy. On August 1, United Healthcare (UHc) revealed its new coverage guidelines titled, ‘Ablative Procedures for Venous Insufficiency and Varicose Veins’. The purpose of the guidelines are clear in the fact that they are designed to limit utilization of phlebology services, namely thermal ablation of saphenous veins and perforators. The content of the coverage criteria also reveals the outright lack of evidence based literature to support these decisions. If you review the document in its entirety, there is no mention of adjunctive procedures. You might ask if this was a mistake or overlooked by UHc representatives. Be certain, this omission was no mistake.
In a recent conference call with UHc representatives, I learned that a panel of physicians spent months developing rules they could agree upon. These guidelines included specifics pertaining to duplex documentation of reflux, vein diameter qualifications, photographic requirements, and a patient affidavit. When asked about the panel’s composition and knowledge of phlebology, it was reported that only one participant was considered a phlebologist. Furthermore, it was shared that the diameter requirements as shared in the existing guidelines, was determined to define what is considered reconstructive when it comes to managing venous disease. One can refute many features of the policy on scientific data alone, but for now we are committed to reporting the necessary features, and submitting comprehensive documentation through an encrypted electronic portal with the carrier.
What is next? What can be done to combat the draconian measures taken by commercial carriers? It is certain that thousands of practices in specific geographic regions have been affected by these simple policy changes. These practices cross disciplines to include vascular surgery, interventional radiology, dermatology, plastic surgery, vascular medicine, and Phlebologists alike. Nobody has been spared. In particular, no physician or office staff will perceive the changes in this plan as a means to relieve their work load. What this represents is rather a unique opportunity for organizations focused on vein care to find common groundin protecting our specialty from the arbitrary whims of a publicly traded company. In fact, an intersocietal task force could not only stem the tide as it currently stands, but form bonds to effectively manage crises in the future. We have not seen the end to this story and the only remaining question lies in what will represent the next crisis. If organizations are able to work together in a proactive means, everyone will win, including our patients. Remember, the worst case scenario is not limited reimbursement for our work, rather NO reimbursement for ALL phlebology procedures.
