Egregious Physician Charges for Varicose Vein Procedures
There are multiple treatment options for varicose veins, including endovenous laser ablation, sclerotherapy, ligation with or without striping, and others. Some procedures are performed in a physician’s office location while others may be performed in an ambulatory surgery center or hospital outpatient surgery department. There are also low-cost options to vascular surgery; recommendations for the most appropriate treatment options are determined by the practitioner. Many insurance plans cover varicose vein treatment that is deemed medically necessary. Treatments for cosmetic reasons are typically not covered.
The average cost for each varicose vein treatment type varies widely depending on the specific procedure/service performed, often in the range of $500 to more than $14,000. Out-of-pocket costs depend on the severity of the varicose veins, all medical fees, if patients have insurance and what the health plan covers.
Egregious Physician Charge Examples
A female patient had the same two procedures for the treatment of varicose veins performed in the physician’s office on two different dates of service.
A physician in New Jersey performed CPT code 36466, defined as injection of non-compounded foam sclerosant with ultrasound compression maneuvers to guide dispersion of the injectate, inclusive of all imaging guidance and monitoring; multiple incompetent truncal veins (e.g., great saphenous vein, accessory saphenous vein), same leg.
Claim One
CPT code 36466 – RT was billed on Jan. 8, 2025, place of service 11 – Office.
Total procedure charge: $61,320.
ClaimDOC pricing: $1,802.71, based on the Medicare 2025 physician fee schedule with markup.
Claim Two
CPT code 36466 – LT was billed on Jan. 10, 2025, place of service 11 – Office.
Total procedure charge: $61,320.
ClaimDOC Pricing: $1,802.71, based on the Medicare 2025 physician fee schedule with markup.
FAIR Health Data
According to FAIR Health data, a physician charge for CPT code 36466 located in New Jersey ranges from $2,217 to $8,516 for this service. A physician charge of $61,320 is egregious for procedure code 36466 performed in a physician office.
The Takeaway
Charges billed by physicians for services/procedures vary greatly. Whenever patients have the option, they should utilize price look-up tools, get clear estimates of charges from the practitioner prior to the procedure/services being performed, and consider alternatives regarding where to have procedures performed. Some providers may be willing to negotiate the cost of treatment.
The improper reporting of services, coding/billing errors and egregious charges can complicate matters for members to understand their healthcare bills and payments, impact the collection of patient balances, build a reputation of providers charging high fees, create burdens for patients having no insurance, and a host of others.
When an individual receives a bill for healthcare services appearing questionable/inappropriate, an inquiry to the provider and/or health plan should be made to obtain an explanation of the services, corresponding charges and reimbursement.
Our goal at ClaimDOC is to use benchmark charges and costs nationally to negotiate fair and ethical payments. Our high-quality and expert review of claims identifies and prevents improper medical claim payments and maximizes long-term cost savings opportunities. Employers turn to us seeking to establish fair reimbursement rates for their plans allowing them to save money and provide richer benefits to their employees. A win-win for everyone.
Background
ClaimDOC’s comprehensive line-by-line review of claims uncovers errors that basic claim repricing and auto-adjudication does not catch, leading to greater savings for health plans and its plan members. Our audit team analyzes all types of healthcare claims for a variety of potential concerns including excessive usual and customary charges, duplication of claims, incorrect coding, unbundling of services and many others. Our claims review is not intended to impact care decisions or medical practice.