Affording IVF

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The Costs Before IVF – Diagnostic and other workup costs

IVF costs
Getting ready for an IVF cycle can be a costly journey!

So last time I talked a little about why an advertised IVF price may not actually reflect you total costs, today I want to keep going on the same topic and focus a little more on the potential costs leading up to your IVF cycle. Assuming the clinic is being completely straightforward with their IVF pricing and explanations you should be able to plan your IVF costs pretty accurately (Hopefully you only need one cycle to get pregnant – average is 2 – 3). The problem is that it can take a good deal of work and money to get you ready for your IVF cycle.

The diagnostic phase or workup is an integral part of all fertility treatments. Put quite simply, if you don’t know the source of the problem, it can be hard to fix it. A thorough diagnostic workout allows the doctors to tailor their treatment to maximize your chances of success. Not really something you want to skimp on. It is far better to spend a little more money upfront than to waste more later on unrealistic treatments that have little chance of succeeding.

Of course, if your clinic is already recommending IVF it means that they probably have a good reason to do so, either it is the best course of treatment due to your age/case or that you have already underwent most of your workup.

Even if you have already done some diagnostic work, most clinics will have a more thorough workup that they have their IVF patient go through. These diagnostic tests can cost thousands dollars depending on your insurance coverage and your particular case. The good news is that many insurance companies will cover some of the diagnostic costs. Insurance coverage for IVF is less common so once IVF is decided any workup required to get you 100% ready for your cycle would no longer be considered diagnostic.

There are a few things that can add large additional costs to your cycle such as endometrial polyps or fibroids. These often require surgical intervention, and what’s worse, polyp removal is often seen as a fertility treatment – since you are getting it removed to prep you for your treatment – and might not be covered by your insurance. Adding many thousands of dollars to your final bill!

The main thing you can do is be prepared for these costs. It can be difficult for a clinic to give you an exact price before actually talking to one of the doctors, as they will not know which tests will be required. After you see the fertility MD you should be able to get a good picture of what the recommended tests are, and hopefully a picture of the financial costs of any diagnostic testing or procedures required to get you ready for your treatment. As always, if you are confused about any of the prices be sure to ask your doctor’s office.

Cheers!

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Looking Past the IVF Sticker Cost

IVF costs
A little dramatic, but the total cost of your IVF cycle may be a whole lot higher than advertised.

Hello, I regret that it has been a busy week so I am just now getting a new post off. I will do better in the future! Today’s topic is going to be why you should look a little closer at any clinic advertising cheap IVF cycles. There can be a whole lot of additional charges involved the process and your cheap IVF cycle may get a whole lot more expensive.

One of the problems with putting a single price tag on something as complicated as an IVF cycle is that not every doctor/clinic will carry out the procedure in exactly the same way. More importantly, different clinics may include or exclude certain auxiliary procedures that may not be needed in every case. They can then charge extra for these services – resulting in a higher bill than expected. While this makes perfect sense, as they might be doing more work in certain cases and should be compensated for their work, the tactic can surprise patients with unexpected charges. In my time working with patients, I have noticed that it is not necessarily the total cost of the services that surprised or upset patients as much as the fact that the charges were unexpected. Most fertility clinics try to make their costs known to patients, but this can vary tremendously depending on where you go.

Unfortunately, this is reflective of one of the core issues in healthcare today. That prices and costs to consumers are generally opaque to them. It is very difficult for a patient seeking care to get a concrete price for their care, and to compound the issue, when someone really needs the care, they often don’t have the liberty of time to shop around for the lowest price (not to mention the fact that patients want the best care possible and there is no easy way to compare similar services from different doctors/clinics).

One simple issue can be that the clinic will have a financial discussion earlier on in the process and during the course of treatment something unexpected comes us that requires an additional service (ICSI is probably the most common one). The clinic may have even mentioned the possibility of the additional service in the financial discussion, but it might not have been emphasized much or the patient just forgot it with the multitude of other information they were trying to absorb.

Another thing that can help patients sort through all this stuff is just being proactive. Ask, ask, ask! Ask your financial counselor if the lump sum you paid includes everything required, or what are the common additional procedures tacked on. More importantly, if you are unsure, or confused by the costs – ask your clinic for help. They would much rather have to take a few more minutes out of their day to explain something that you might not understand than have you find out unexpectedly and be upset. As much as they want to help you, they can be really busy sometimes and can assume you heard them the first time. If not, give them a little nudge to get another explanation.

From the clinic standpoint it is important to beat this stuff over your patients heads as much as possible (I mean that in the nicest way possible!). You want to do your best to make sure the every patient is aware of what they will be charged, and what possible additional services might be needed. You want to give them the best, more clear picture of the possible costs as you can. They will thank you for keeping them in the loop!

Cheers!

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How a cheaper health insurance plan can save you money

choosing an insurance policy
Choosing the best health insurance can be a tricky endeavor!

This article is mainly for those of us lucky enough to be self insured, but I think anyone who has any ability to pick their healthcare plan could possibly benefit from it. I am going to tell you how the cheaper insurance policy could be a much smarter way to go. This topic makes me think of the old adage “You don’t truly appreciate the value of something until you pay for it yourself,” or something along those lines.

Selecting an insurance policy for yourself or your family can be a daunting decision. While everybody wants to get the best coverage possible – the reality is that health insurance is really expensive. Expensive enough to make one think that: welI, I am hardly ever sick. What is the harm in not having insurance for a few months/years? I won’t lie, when I was between full time jobs, and doing some freelance work on my own I let my insurance policy lapse for a few months before my common sense dictated that I set up my own policy in the interim. In this day in age where a minor surgery will cost you 10-20k out of pocket without insurance, and something major could run you into the 100’s of thousands of dollars – it just doesn’t make sense not to have some kind of financial protection from what would be a veritable mountain of debt. A debt that could possibly haunt them for the rest of their life.

So there are a few things to consider when shopping around for an insurance policy. The main ones to look at are

Monthly premiums – how much money you will be spending each month to maintain your policy.

Deductible – how much money you will have to spend on medical bills before your insurance policy kicks in (note: having insurance will get you lower rates at any doctors that are in network for your policy).

Max out of pocket – the maximum amount you will spend in any plan year of your policy on eligible medical expenses. This is an important one! Why, you ask? I will get to that in just a second.

What it actually covers – AKA the fine print. What exactly is considered an eligible medical expense? Does the policy cover things like eye care? Or infertility treatment? The important thing is to be aware of any possible things that you will likely use the insurance for and if they are covered or not.

The main thing to think about when selecting an insurance plan is to figure out it will cost you. This is not quite as simple as multiplying the monthly premium by 12 and calling it a day, although, that is an important piece of information. You also want to consider what the cost to you would be if you got really sick, and needed to be hospitalized. I.E. what is the deductible of each policy you are looking at and what is the max out of pocket. If you are hardly ever sick and almost never go to the doctor, it doesn’t make much sense for you to pay extra each month for a low deductible policy. A policy that would save you a few buck if you went to doctors just a few times a year, but would end up costing a lot more in premiums. You want to think of what will be your total health care costs on each insurance policy.

The deductible can be an important piece of data to consider when figuring how a policy will impact your total health care costs. Lower deductibles mean that the insurance benefit will kick in sooner. If I had a $100 deductible on my policy and I went into the doctor for $300 dollars of care I would pay 100% of the first $100 and that would satisfy my deductible. The next $200 would be processed at my coinsurance amount. For example, if I had a 80/20 coinsurance benefit on my policy, it would mean that out of that original $200, I would be responsible for just $40. Sounds pretty nice right? The lower the deductible the more you will pay each month. So again you have to consider how often you actually use medical treatment. If you are not someone who goes to doctors very often it is not very important to have a low deductible when it is costing you more money in premiums each month. As long as the money you save by not having a low deductible is more than the money you will save by having a low deductible than you are better off not having a low deductible, and vice versa.

One of the most important things to look at is the max out of pocket costs section on your policy. This little piece of info tells you how much you will have to pay if things really hit the fan. If my policy has an out of pocket max of 5k, and I get into accident and need some serious care, I know I will not have to pay more than $5k. For me, someone who doesn’t need much medical care, but wants to have insurance to protect myself from the potential life-changing amount of debt that an accident could give me, this is a very important. I save a lot of money each year by going with a higher out of pocket max. You should look at your total costs though, and a lower max out of pocket could make sense for you if you have kids, or need more medical care.

Also factor in any regular care that you need, and if it is covered or not. For example, I wear contacts and every year I need an eye exam and new contacts – about a $250 annual expense without insurance. I would then factor that in when looking at the total cost of the policy. If the policy covers that expense 100%, cool, I know that will save me $250 bucks a year. However, if this policy costs an extra $500 from a similar policy I am looking at and there are no other differences that matter to me (think long and hard about this) then I am basically losing $250 bucks a year by going with the additional coverage. You then take these numbers and see how they affect your total health care costs for the year.

You should take all these factors into consideration when selecting your insurance policy and go for what you think will end up costing you less money in health care expenses. As with many financial decisions, it is much more important to look at the long term costs and go with whatever makes the most sense. I went with a high deductible, moderate out of pocket max because I am not often sick or needing medical care. I figured that the amount of money I save each month on premiums to be well worth the cost of a few minor doctors’ visits, if I for some reason I needed the additional care. I can bank the addition costs and spend/save them for something else. If I was someone who went to the doctors on a regular basis, then it would be more important to have a lower deductible.

I hope I shed some light on the things to think about when shopping around for a health insurance policy and why a cheaper plan can save you money, and be the smart choice. If you have any questions about any of this don’t hesitate to ask! Happy healthcare shopping!

Cheers!

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Shared Risk Programs

IVF Refund Programs
Read all about the risks and benefits of shared risk programs

What are they?

Shared risk programs, aka IVF Refund programs, are an interesting vehicle for reducing the financial risk of having to undergo multiple IVF cycles. Getting pregnant through IVF, despite the best efforts of the brightest physicians and doctors around the world, is still an odds game. Patients trying to get pregnant through IVF are basically rolling the dice for a successful pregnancy. Depending on your age and condition, these odds can vary from under 10% per cycle to upwards of 75/80%, if using donor eggs. As such, it is not uncommon for patients to need several rounds of IVF treatment in order to take home a baby.

IVF is not an inexpensive treatment and the financial burden of having to go through many cycles of treatment can be overwhelming. To help put fertility patients financial worries at ease clinics developed programs that would, for eligible patients, put limits on the potential costs of their treatment cycles. You can think of them as a form of infertility insurance that helps protect the patients from financial loss. And thus shared risk programs were born.

How do Shared risk programs work?

Essentially, these programs offer patients a flat-fee that will cover a set amount of treatment cycles and, if the treatment is not successful, offer a partial or full refund of those fees. These programs are beneficial to both parties. They give patients a clear amount that they know will get them to their goal of getting pregnant, or they will get a refund that they can use to pursue alternate avenues of reaching their goal. For the clinic, there are several benefits: they allow them to collect a larger fee (usually the equivalent of several full IVF cycles) upfront from the patients; since it is a flat fee collected, the clinic stands to make a profit if they can get the patients pregnant on the first cycle with decreasing profits with subsequent cycle. However, the clinics will lose a lot of money if they are unsuccessful and cannot get the couple pregnant. In this fashion both parties share risk. The patient might end up paying a little more for their IVF costs, but have the ability to cycle several times and even get their money back if all cycles are unsuccessful. The clinics have the opportunity to collect a greater fee if they provide quick success, but also balance that with the potential of losing part/all of their fees if the treatment ultimately doesn’t work.

How much do shared risk programs cost?

These IVF refund programs usually cost between 2x-3x the cost of a single IVF cycle, and will usually cover all clinical appointments and procedures required in the cycle. Cycle medications are almost always extra as they are sold by third party pharmacies so be aware there will be additional costs each cycle that will not be refundable. If you are choosing to participate in a shared risk program I would clarify this detail, and make sure you know what is and is not included in the program fees.

What are the eligibility requirements for Shared Risk Programs?

Since the IVF clinics bear a significant financial risk in offering these types of programs, and that the average success rates of IVF range between 10-60% depending on the age group they place restrictions on who can sign up for this type of program. It is in their best interest to offer this type of program to the patients who get pregnant most easily. This means an age cutoff and other medical qualifiers that like normal day three hormonal panels, a normal uterine cavity, and sperm parameters within certain ranges. These will vary clinic to clinic, so if you are interested in this type of option be sure to ask your doctor if you are eligible.

Are Shared Risk Programs Ethical?

Shared risk programs have been reviewed by the Ethics Committee of ASRM (American Society of Reproductive Medicine) and found to be perfectly ethical. They ruled that “that shared risk programs may be viewed as a form of insurance against the risk of failure that might appeal to some couples seeking IVF. The appeal arises from the general absence of health insurance coverage for IVF”. They concluded that as long as clinics were upfront with the costs and benefits of such programs vs regular pay-per-service models, and did not create false expectations, or promises, shared risk programs were an ethical and potentially valuable method of paying for treatment.

Should I use a Shared risk program?

This is not an easy question, and certainly not one I should be answering for you. Shared risk programs offer a great way to control the costs of your fertility treatment, but at a potential higher cost if you are successful right away. You should carefully weigh the benefits and risks the program(s) offers you and make your decision after considering what is best for you and your family.

What is the best Shared risk program in the Pacific Northwest?

Now down to the nitty gritty. This is not an easy question, and as a Seattleite I admit I did not fully research the options in Idaho or Oregon. However, after looking at the programs offered by all the major clinics in the area I have concluded that the Peace of Mind 100% IVF Refund Program offered by Overlake Reproductive Health to be the most comprehensive program out there right now. It rises above the others programs such as Seattle Reproductive Medicine’s Attain IVF Refund program, or Oregon Reproductive Medicines IVF Refund Program in that it offers a complete refund and more treatment cycles! So if you are considering an IVF refund program and live in the Seattle Area then ORH’s is the best one out there right now.

Well there you have it. I hope I was able to answer your questions about shared risk programs. As I said in the beginning of this article these refund programs are an interesting vehicle that offers patients a means to help control the costs of their infertility treatment. If you have used a shared risk program before, have any questions or comments, or just want to say hello, please do so in the comments.

Cheers!

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Coding and IVF Health Insurance Coverage

fertility coding and billing
It is very important that your fertility treatments get coded correctly

Correct coding is important for you—the IVF patient—as well as your medical providers and their accounting staff.  While ICD-9 codes relate to diagnoses, CPT codes denote specific procedures.  In order not to receive a denial on a health insurance claim, the CPT codes entered on each insurance claim must correctly correspond to the ICD-9 codes.  Clinicians and billing staff sometimes make errors in coding, and a health insurance claim may be denied simply on that basis.  The stated reason by the insurer for denial of payment is often that the procedure was “not medically necessary”. If you think you have gotten one or more claims denied by one of these errors your should contest them.

For in vitro fertilization, the coding can get especially complicated, and errors are not uncommon.  Therefore, understanding the most common codes utilized in IVF health insurance can enable you to check if a claim denial was based on a coding error—and notify your clinic to re-submit the claim.  According to an article in the Journal of the American College of Radiology, physicians correctly coded only 42% of interventional radiology patients.  In a 2010 article by Skelly and Bergus, they found that family physicians’ frequently under-coded their visits as well as made errors in CPT coding.

Some infertility-related ICD-9 codes (as of 2012) include:

  • 628.0 = female infertility, associated with anovulation
  • 628.2 = female infertility of tubal origin (e.g., fallopian tube blockage)
  • 256.4 = polycystic ovaries
  • 752.19 = other anomalies of fallopian tubes and broad ligaments
  • 617.1 = endometriosis of the ovary
  • 617.2 = endometriosis of the fallopian tube

Typical CPT codes related to IUI and IVF include:

  • 58322 = insemination
  • 58974 = intra-uterine embryo transfer
  • 58970 = oocyte (egg) retrieval
  • 89280 = intra-cytoplasmic sperm injection

While ICD-9 coding can be exasperating and labor-intensive—especially for clinicians—it serves an important purpose in medical and healthcare research as well as governmental rate-setting departments.  For public health researchers, the ICD-9 codes in electronic medical records can provide an indication of changes in the prevalence of specific health conditions (e.g., pediatric asthma, pediatric Type 2 diabetes, and HIV ).  By searching on specific ICD-9 codes, researchers can acquire data to gain a better sense of emerging trends in health conditions.  The relationship of IVF to multiple births was acquired in part as a result of research utilizing codes in medical records.

On the other hand, the complexity of coding presents an administrative challenge to reproductive health clinics requiring a sizable billing staff—and may be a factor in the increased costs passed on to patients.

Many insurance companies include nurse case managers as essential staff whose primary role is to review and seek ways to deny claims.  The inclusion in most health insurance policies of a clause specifying that treatment be “medically necessary” provides a convenient loophole to deny treatment—especially high-cost treatment.   Even those insurance companies that cover in vitro fertilization are focused on finding ways to deny claims to reduce their expenses.  By maintaining narrow parameters for CPT codes to correspond to ICD-9 codes, they can limit their coverage.  Therefore, your diagnosis as entered in ICD-9 codes is very important in terms of payment by insurers for procedures and tests by your clinicians.

Being aware of the implications of coding on the actual costs covered by your health insurance plan can enable you to ensure that you are not being short-changed in the claims approval process.  After all, IVF is expensive enough without receiving a bill from your clinic for something your insurance should have covered.

Cheers!