Expert's Perspective

Outsmarting The Fox and Other Insurance Fables

Do you know the Aesop’s fable of the Stork (Crane) and the Fox? The Fox invites the Stork to dinner only to serve her soup in a very shallow bowl that she cannot eat from. Sound familiar? Is your insurance company foxing you out of coverage? You may need to do what the Stork did, be prepared to get even.

Insurance companies are sneaky with the details, fine print and technicalities. Top of my mind is a lesbian couple whose insurance company required they do 5 IUIs or IVF before covering care. That couple obliged, paid for five cycles, suffered a chemical pregnancy on the final IVF and were told by their carrier to start again because “they succeeded in getting pregnant”, and didn’t qualify as infertile. If you think insurance companies limit themselves to solely hoodwinking and tormenting same-sex couples, you’re mistaken.

Being in business with your insurance carrier can be like dining with the fox, and when it comes to fertility, you need to be prepared with your own cutlery.

Learn Your Coverage Limits


First of all, learn the limits of your fertility coverage and find out what is, and is not, covered. Where the policy was written can matter. For example, if you live in Arizona but work for a Massachusetts company, and the insurance policy is written in Massachusetts, then you may have mandated coverage for fertility treatment and medication.

You may have coverage for the diagnosis of infertility, but not for the treatment of infertility. Your benefit may cover IUI but not IVF. Coverage for IVF does not mean that cryopreservation of the embryos and storage is included. Know the coverage so that you are not surprised by the out of pocket non-covered expenses.

If you work for a large company, ask HR to provide you the details and if you work for a small company, contact the person who sold your company the policy.

Pre-Auths & Relying On Your PCP Or OB/GYN


Second, find out who needs to sign-off on your receiving treatment before the insurer will pay for it. This is called “Pre-Authorization”. Some insurers will want a doctor to see you and refer you to a fertility doctor. The insurer may also want to be notified ahead of time.

If you have coverage, make sure the referrals and authorizations are ordered before you start treatment. Sometimes getting the basics from your primary care provider or OB/GYN will save you money, like the day 3 labs and maybe the hysterosalpingogram (HSG).

In cases where you do not have fertility coverage, having a primary physician order the testing as part of a “wellness check” may get you coverage for the testing because the coding for the tests will not be for fertility care.

Once you see a fertility specialist, some insurance companies are reluctant to cover hormone testing if they feel it is only for a fertility diagnosis. Prior to your first appointment with the fertility specialist, call ahead and find out if there are tests you can have done with your primary care physician before you have your fertility appointment. We often give patients a list of testing and the timing of testing so that they can complete this before their initial appointment. This will save you time and may help your fertility doctor give you a diagnosis in your first appointment.

Deductibles & Treatment In A Year


Third, know what the out-of-pocket expenses and deductibles are and figure this into your treatment plan. As a reminder, a deductible is the amount of money you have to pay before your insurance starts to pay. In my plan, once I meet my deductible, $3,000 per year, my plan pays 100% of the covered services under my plan.

When it comes to deductibles and out-of-pocket costs, timing of treatment matters, big time. Let’s say you are planning to do a series of IUIs and then IVF if you do not conceive. You have a $2,500 annual deductible and you have coverage for both IUI and IVF. If you start in January with your IUIs, then by say June, you have completed 3 cycles and paid $2,500, all of which goes to your deductible. The subsequent IVF cycle in September is now going to be covered completely. If, however, you do your IUIs in July, September and November (again in our example, paying the $2,500) and then do the IVF cycle in January of the next calendar year, you will have to pay $2,500 again, as this is a new year and the deductible resets. By doing all of the cycles in one year, you save $2,500.

Don't Get Stuck Paying The "Insurance Contracted Price"


Fourth, understand how much of your treatments your plan will cover. In the fertility world, clinics, labs and pharmacies often have a “cash pay” price and a “contracted insurance price”. The “cash pay” price is often less than the “contracted insurance price” and in some cases, you’re way better of paying in cash for the lower rate.

For example, the bill for an ultrasound if you pay cash may be $100. If the clinic does not receive cash up front, they will bill your insurance company the “contracted insurance price”, say $200. They know your insurance company will delay payment for 30 days, discount this billed amount, may deny the claim requiring resubmission, etc. and, in the end, if the clinic is lucky, they’ll get paid $100. So the clinic starts high because they know they are dealing with a ruthless entity.

What happens when a patient thinks this is covered, tells us to bill insurance, and insurance denies it? The patient is now left to pay the “contracted insurance price” of $200, when all along she could have paid $100 in cash up-front.

These are awful situations when they arise, and they happen all of the time. The patient is understandably outraged (paying a higher price for the same treatment). But so is the clinic: we’ve waited months to be paid and lost hours on the phone trying to figure this out. And yes, that adds up. Say each billing person costs the clinic $25 per hour and this ultrasound took us four hours to resolve. Our expenses for providing this treatment have swelled.

This also may apply to medication, including very basic medications. I have had patients who have fertility medication coverage only to discover that the coinsurance is more than the cost of the cash pay medication.

For example, a patient had a pharmacy deductible of $3,000 for the year (thereafter drugs were were covered 100%). The cash pay price for her medication at our local fertility pharmacy was $1,500. But that very same pharmacy wanted to bill her insurer, Caremark, $3,000. Sounds crazy but this happens a lot.

Let’s now play this through. Had she paid in cash, she could have bought two rounds of medication, at $1,500 each, and met her $3,000 deductible obligation. Had she let Caremark pay, she would have still needed to meet her $3,000 deductible, and received only one round of treatment. No question what was the better move but these things can be hard to foresee without investigating the details.

Agent's Name, Rank & Serial Number


Fifth, whenever you talk to your insurance company note the time, date and who you are talking to (get a name, and ID # if they have one, and where the call center is located). This is valuable information. The insurance companies record their calls. If someone tells you that you have coverage for medication or a procedure and then they deny the claim, you can have the insurance company look up the conversation and replay it for you.

If the insurance company continues to deny the claim, you’ll want to include this information when you submit your appeal. This has helped a number of my patients who have had denied claims get payment, in one case, even when they did not have coverage, but the representative told them they did. Their meticulousness saved them over $10,000 in treatment costs.

Get The State Regulators Involved


Sixth, know where and how to submit and appeal denied claims. Have your physician write a letter (help them out by getting the names and addresses of who you need to address the appeal to). Always copy your state’s Department of Insurance (or whatever they call themselves) on every appeal submitted. Call the department of insurance for help. I am stunned at how effective these groups can really be.

In our state, Arizona, our Department of Insurance can help if your initial claim is denied. They can help you re-appeal the appeal and will watch for any violations of insurance code. I will often have my patients copy the Arizona Department of Insurance on their initial appeals letters. This serves two purposes: first, it gets the insurance companies to wake-up and realize they are now being monitored. Second, if the Department of Insurance needs to get involved they have evidence of your appeal and can act more quickly.

Moral of the Fable: By asking questions and understanding your medical insurance policy and coverage you will not be out-foxed. This will give you the best prices for services and you will be prepared for the cost of fertility treatment.