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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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!

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When a Higher Cost Health Insurance Plan Makes Sense

Save money by paying more for insurance
You can sometimes save money by opting for the more expensive health plan..
The costs of medical care are sky-rocketing in the United States, and this includes in vitro fertilization (IVF).  If you live and work in a state that does not mandate IVF health insurance coverage, then you might want to consider relocating if your health insurance plan excludes IVF coverage.  It might actually save you financially in the long-term!  According to a 2011 article published in Fertility and Sterility by Patricia Katz et al, a total expenditure of $61,377 was the median cost per successful IVF patient outcome among their study subjects.1  Since the Affordable Care Act does not mandate IVF coverage, it may be difficult to obtain insurance providing IVF coverage outside of the 15 states that do.  If your employer does offer health insurance covering IVF, it may be preferable to choose one with a higher monthly premium if it covers more of the possible costs incurred in the course of your medical visits.

In preparation for IVF, hormonal therapy (i.e., GnRH agonist, follicle-stimulating, and/or luteinizing) will likely be initiated by the physician that may involve daily injections for a couple of weeks.  In August 2012, an article published online in Reproductive Biology and Endocrinology by Sills et al reported higher non-reimbursed medication costs for GnRH antagonists than GnRH agonists.2  Their finding illustrates the importance of clarifying the medication coverage of your specific health plan.

A huge surprise to patients of outpatient clinics at medical centers is that the organizational units generally bill separately.  Therefore, you can receive a separate bill for the office visit, lab tests, pharmacy, and other treatments.  Insurance companies view these as separate claims—and each must be coded correctly for reimbursement.  Many health insurance companies cover medications provided at a medical center and by prescription for use at home at vastly different rates.  If you are unsure of whether your insurance will cover your entire hormonal treatment regimen, contact your health plan’s Member Service representative to understand the coverage terms before you receive a walloping bill!

Even if you are lucky enough to have an employer-paid plan—or an individual policy—that covers the costs of IVF, you need to discuss the terms of coverage with a Member Services representative to ensure that you understand what procedures, lab tests, and pharmaceuticals your insurer will cover.  Clinical staff are hired at health insurance companies to review claims and seek loop-holes to cut costs.  If any therapy undertaken does not meet their exact parameters, they may deny the claim.  If you feel it should have been a covered expense, submit your grievance in writing within the time period allowed by the insurer.  This can result in a reversed decision in your favor—saving you money.

Assuming you don’t plan to pay out-of-pocket, one of the most important decisions you make related to undergoing fertility treatment may be your health insurance.  For that reason, it is wise to plan ahead for the financial costs.  Do you really want IVF or would adoption be a viable alternative for you?  And, the fertilization costs are just the beginning—having a baby is expensive!  Seeking the advice of a financial planner may enable you to budget better for the non-covered costs involved in your fertility treatment regimen—not to mention pregnancy-related costs!  The stress involved in parenting is enough without adding a medical debt burden to the stew.   Outcome uncertainty inherent in undertaking IVF makes it vital that costs—offset by a sound choice of health insurance coverage—be considered along with the emotional need to have children.  After all, you could have twins!

Hope this was helpful! If you have any comments or questions please don’t hesitate to write them below.

Cheers!

References:

1)      Katz P, Showstack J, Smith J, et al.  (2011).  Costs of infertility treatment: Results from an 18-month prospective cohort study.  Fertility and Sterility 95(3): 915-921.

2)      Sills ES, Collins GS, Salem SA, et al.  (2012).  Balancing selected medication costs with total number of daily injections: a preference analysis of GnRH-agonist and antagonist protocols by IVF patients.  Reproductive Biology and Endocrinology 10:67.

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Understanding Health Insurance Terminology

health insurance terminologies
Confused by the jargon? Find out what your health insurance is talking about!

This post is going to focus on explaining what some of the myriad terms and acronyms that insurance companies and your doctor’s office often use to describe and/or explain the particulars of your medical benefits. It is important to know the definitions of these terms as they can and should affect your decisions when it comes to your personal health care. These definitions are meant for general educational purposes only. You should read your benefit booklet obtained from your insurance for any plan related specifics or how these concepts apply to your policy. This list could grow as I add more and more terms.

Definitions

Coinsurance (%): A cost sharing part of a health insurance plan that requires the insured party (you) to pay a stated percentage of the eligible medical expenses after the deductible (in most cases) is paid. Coinsurance rates may vary depending on your policy, type of service rendered, where the service was rendered, and if your deductible has been met.

Copay or Copayment: Another cost sharing device that requires the patient to pay a stated dollar amount at the time of service. The insurer is responsible for the remainder of the days services/claims. Any amount that the insurance doesn’t pick up or invalidate will become your responsibility. The copay amount can vary depending on the type of service, where the service is obtained, and possibly if your deductible has been met.

Deductible: A fixed amount per benefit period that must be met before the insurer starts to make payments for covered medical services. Having a lower deductible means that the insurance company coverage will start sooner. Ex. If your deductible is $250, then you are responsible for the first $250 of eligible medical expenses and any eligible expenses over that $250 would be processed with your regular coinsurance. The deductible may vary depending on several factors including type of service, and network status (in network/out of network). Plans may have individual and family deductibles.

Flexible spending accounts or arrangements (FSA): These are special accounts offered by some employers that provide a way for employees to set aside a portion of their income, pretax dollars to be used for health care costs, including costs not usually covered by your insurance company. Some employers will make contributions to these accounts. The common downside of such accounts is that the funds must be used within a benefit year or they can be forfeited. Some FSA’s can be set up for other costs such as childcare.

Maximum plan dollar limit: The maximum amount that the insurer will pay for covered medical expenses. Plans can have a yearly, or lifetime max, and often they can have different maxes for some services. I.E. a $10k lifetime infertility benefit, or a $1 million lifetime plan maximum.

Out of pocket max: The maximum dollar amount a covered member is required to pay out of pocket during a benefit year for all covered expenses. After this is met, all covered expenses will be paid at %100, no matter what your coinsurance is, up to the lifetime maximum.

Premium(s): The agreed monthly/quarterly fees paid for your coverage; health, car, home or otherwise. These can be paid by your employer, you, unions, etc.

Primary care physician (PCP): a doctor that you elect to serve as your primary contact for any medical care. Think “family doctor”. Under a managed care plan your PCP would provide basic medical care, and coordinates any/all your referrals for outside specialists.

If I left anything out, or made an error please let me know in the comments. I plan on adding more terms as they come up :)

Cheers!

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Contesting a Denied Insurance Claim

denied insurance claims
Denied insurance claims can be a nightmare – Read how you can contest them

Your insurance company denies one or more of your claims and all of a sudden you are responsible for paying the bill. This scenario is uncommon in other fields of medicine, but can happen all too often in the field reproductive endocrinology. Infertility treatments are often viewed as elective, and as such coverage of such services can vary dramatically from plan to plan. Today I will go into more detail about why this happens and, more importantly, what you can do to contest your insurance company. But before I go into more detail I want to give you some advice: If you are seeking fertility treatment to help you conceive I recommend learning what your benefits are!

Why claims can be denied

As I briefly touched upon above, one of the roots of the problem with insurance coverage for infertility is that every policy seems to have a different degree of coverage. It is fairly common for a policy to have diagnostic coverage, where they will cover services and tests to determine the nature of your infertility, but no coverage for treatment. Treatment can be defined as to any service that is carried out with the goal of getting you pregnant. To further complicate this picture, when an insurance policy does cover infertility treatment, exactly what treatments it covers is unique to that individual policy every time.

To make matters worse, each insurance company can have slightly different definitions of how each service is classified. For large items like an IVF cycle or IUI cycle, there is usually very little uncertainty. However, for smaller things like certain diagnostic tests, the answer of coverage can be unclear. To make matters worse, the insurance company cannot/will not always tell the clinic if something is covered or not. So even if you ask your clinic, and they talk to your insurance company for you, they might not be able to obtain a clear answer. Very frustrating for both the clinic and the patient. If you have ever spent some time on the phone with your insurance company, you will know what I am talking about.

Okay, so you may be thinking that the whole thing sounds terribly vague and disheartening. Despair not! If you happen to find a charge on your bill or on your Explanations of Benefits (EOB) that you think was denied incorrectly you can contest it.

Contesting a denied claim

As the patient, you have the power to contest any denied charges with your insurance company. That being said, you should only contest claims that you believe were processed incorrectly. Example: If you know you don’t have coverage for IVF and your insurance denies the claim, it is a waste of time to try and contest it. If you have something that you believe should be covered under your particular insurance benefit.

Rule #1 (my only rule here actually): Document everything! Take notes on who you talk to, their extensions, or how you can talk to them again, and any pertinent details of the conversation. This can save you tons of time!

First thing you should do is talk to your insurance company. Call the customer service number to get the details of why the charge was denied. The more details you can gather the better, and write down the name and extension of the person who helped you. Find out exactly why the service was denied. Was it because it was classified under an ineligible benefit, hopefully due to a billing error at your clinic? Was the service not deemed medically necessary? Depending on their answer you will have different courses of action.

If you think the denied service was billed incorrectly, call the clinic to make sure they billed it correctly. It is uncommon, but sometimes this can be the result of an incorrectly entered CPT(procedure) or ICD(diagnosis, or DX) code on their end and just having them correct the error and resubmitting the service can solve the whole thing.

If the service was denied due to not being “medically necessary” (common for uterine polyp removals) the course of action is to escalate the issue with your insurance company. They will ask your doctor for chart notes and sometimes a letter explaining why they think the procedure was necessary. The insurance company usually does the following up in this case, so your work is done for now.

My last advice to you is to make sure you follow up on your case! Medical offices, and especially fertility clinics, can be very busy and sometimes it takes a gentle push to get things done. However, make sure you are polite in any of your inquiries, and don’t call everyday! The office usually wants to help you, and often just need a reminder or two. Getting angry, or otherwise unpleasant with any of the staff will get you nothing.

If you have any stories of denied claims you were able to successfully (or unsuccessfully) fight please share them below. As always comments and questions are welcome!

Cheers!