The Complex Care Model
At Lighthouse Complex Care, our model is different from other medical practices because our patients have more unique needs. We use a comprehensive, personalized medicine approach for every patient which includes greater patient access to our providers and more time spent by our providers on each case outside of your appointments.
What is the Complex Care Model?
Patients with multiple, complex medical issues tend to need more comprehensive care and frequent support between visits to stay feeling their best. Many of our younger patients can go from feeling okay to being in crisis in a very short time.
Our patients also have more in-depth case reviews prior to, and between, appointments. We collaborate more often with our patient's other care providers. We spend more time managing supplements and medications because our patients tend to have more of them.
We recognize this need for increased contact time with our providers and have built it into our model to make sure you get the care and support you need, when you need it.
What does the Complex Care Fee provide for our patients?
Your monthly complex care fee represents any time that month when “out of visit” work on your case happens. It includes services like but not limited to:
Access to the after hours triage line;
Case coordination and preparation for every appointment;
Provider consult with other doctors and healthcare providers;
Prescription management and refills in between appointments;
Quick calls or inquiries through the portal or info email line;
Any necessary case research to refine care;
The usual referral process to other clinics and specialists;
Nutritional or supplement help;
Management of medication reactions or support when you or your loved one is sick;
Letters for school, work, or other social support agencies
What is not covered by the Complex Care fee?
Comprehensive lab result follow-up (while we will notify you of any critical abnormal lab results, to go over your labs and move your treatment plan forward, you will need an appointment)
Extensive research or genetic projects (these require multiple hours of investigations and will result in additional care fee hours being accrued or a single project fee can be arranged)
Referrals that require extensive interface such as with the Undiagnosed Disease Network or while outreaching multiple specialists and researchers
Unlimited out of visit consultation
Appointment cancellations with less than 48 hours notice
Will my insurance cover my monthly Complex Care fee?
Possibly. Colorado Medicare will cover this fee. Colorado Medicaid does not. If you have Medicaid, your Complex Care fee will be charged at a reduced rate of $93 per month.
If you have private insurance, your coverage varies by plan. We encourage you to call and ask if your plan covers CPT code 99487. They may also require at least two of your diagnosis codes.
If your insurance provides coverage, your care fee will be electronically tracked and billed to your insurance company. The fee rate per hour that we bill to insurance is $214.48. You will be responsible only if the insurance company submits a denial of the fee.
There is a 40% discount for paying your fee with cash or credit card which brings the fee to $128.69 per month. If you choose to have your fee billed to insurance, the discounted rate is no longer available for that month even if your claim is denied. However, you can switch to cash payment for your Complex Care fee for any following month and the rest of your claims will be billed to insurance as usual.
Can I opt-out of this fee? What if my case doesn’t require any "out of visit work" this month?
No. We only accept patients that meet complex care criteria in our clinic and have found that every patient at Lighthouse Complex Care consistently requires more than an hour of case review outside of appointments.
We have found that while rarely, in some months, patients will not require extra attention, many months, patients will require more. We operate on a system of averages to keep the cost uniform unless there is excessive work required for your case. It is only by charging this fee that we are fiscally able to offer the standard of care we provide.
Are there any discounts available?
There are discounts available for paying cash and for Medicaid patients as outlined above. We also extend discounts to patients who have 3 or more family members being seen at Lighthouse Complex Care.
When is it billed?
Complex Care fees are automatically billed at the end of each month either to your insurance company or to your card on file if you are a Medicaid or Cash Pay patient.