XP: If you have a lifetime max on IF benefits and have used it

lisagab26

I also posted this on 3T..

I know all plans are different, but for you, did some of the procedures/meds, etc not fall under your IF benefit?  Did you find you hadn't used as much as you thought?

I am extremely frustrated.  I've been going back and forth with my insurance company for a couple of months now, trying to determine how much of my lifetime max ($25,000) we have used.  I've insisted they re-audit 3 times because the number keeps coming back absurdly low.  After 3 IUIs and 1 IVF (cancelled before transfer), the are INSISTING we've only used $6,000. 

My RE's office told me meds do fall under my plan, so DH and I calculated to have used at least $18,000.

We are starting stims later this week for IVF#2, so while waiting for final audit results from the insurance, assuming we would not have enough to get us through another IVF cycle, we signed up for a Shared Risk Program and financed a loan to cover it. 

I have left a message with my insurance to get this number in writing, but haven't heard back. I've also now left a msg with my RE's office to see if we can rescind the Shared Risk and loan, should we get confirmation that we still have plenty of $ left to use through insurance. 

This would all be much simpler if the people at my insurance company could give me straight, confident answers.  Unfortunately that is not the case and I always hang up the phone feeling uneasy and still with questions.

Sorry this is so long.  If you have any input, I'd greatly appreciate it!!

kmc84

Is it possible that the numbers you are calculating are oop cost and their numbers are based on what they reimburse? Just a thought, good luck!

hugmonkey

Maximum benefits are usually based upon their reimbursement.  For example, your RE office might charge 7k for an IVF cycle, but your insurance might only reimburse them 4k.  In that instance, only 4k of your benefit would be used.

Does your insurance have a client portal?  You might be able to view all of your medical and pharmacy claims online and then add up  the total they have reimbursed so far.

 

BzeetyD

I kept checking in after each procedure. Another thing is that insurance sometimes runs months behind. I used up the last of my 10k in coverage with a procedure in Nov but didn't hit our $$ til January.

tptbabe

Another possibility is that your office charges different amounts for OOP and to insurance companies. Just something else to look into as well?

lsgabriel

I know when I called my insurance carrier, they told me that they are some things that aren't billed under infertility.   Don't forget that your RE is also a regular GYN, so some things will bill like a doctor office visit. They came back three times with the same number, so I personally wouldn't borrow trouble: they should know more about benefit calculation than you or I.

If it helps your peace of mind, get the CPT codes from  the practice, then call yu insurance company and find out the contracted rate for each one.