what do you think of this? (big $ problem w/IF clinic
LindseyJW
member
a good friend is going through IF treatments in her hometown.
she did a round of clomid, then they discovered MF (low count, motility, etc.). they did IUI at least once, maybe twice. all covered by insurance, except any procedure involving her DH, who is not insured (and not covered on her insurance at the moment). they paid OOP for his procedures (SA, etc.)
then they moved to IVF, all at the same clinic. first IVF cycle was BFN. showed up a couple weeks ago to start cycle 2, and was told she had a $25k balance (the amount of IVF #1). clinic told that her insurance rejected the claim. insurance told her the clinic coded something incorrectly and to resubmit iwth proper coding. she went ahead with IVF #2, after being assured that IVF was a covered service under her plan and that the claim would be accepted with the proper coding. then she gets word from the clinic that the claim had been rejected again (now $50k). insurance now says that they need verification that all other options had been exhausted and that SHE had the IF diagnosis (since she is the insured and her DH is not).
well, she has no diagnosis, it's her DH with the diagnosis. and now she may be stuck wtih $50,000 in bills. PLUS, if this cycle doesn't work, they won't be able to do another, OOP.
the clinic and insurance have said they will see what can be done to cover the past costs, but going forward, different story. what's strange to me is that insurance covered the IUI, but perhaps that was before the MF diagnosis?
can anyone provide advice for her on handling this situation with the insurance or the clinic?
i have to wonder how long the clinic has been in business. it seems to me that they should have known that since DH didn't have insurance and DH had the diagnosis, that her insurance wouldn't cover IVF for her.
Re: what do you think of this? (big $ problem w/IF clinic
Oh my. That is really sad. I feel so bad for her.
The only advice I have is for her to gather all of her paperwork and do her best to question everything and see what they can do. I would ask the insurance company to provide the written language in the terms and conditions that explains why the claim is being denied. If it turns out that she's absolutely going to have to pay it, I would negotiate with the clinic to try and pay a lower amount to relieve the debt (sometimes, they would rather get some money than none at all). If she feels that the insurance company is not doing what they are supposed to do, there are consumer protection agencies in each state that she can contact to get help. Most insurance companies do not want to get in trouble with the state so this can sometimes push them to do the right thing. You can also contact the BBB. Insurance companies DO make mistakes so she should push them. I have had a few times where I fought insurance companies and won. As she goes through this process, she needs to document every single phone call, who she spoke with, what they said, and the date and time. This can be very helpful information.
Going forward, I would not listen to a doctor's office about what will be covered and not covered from an insurance company unless they have written documentation from the insurance company and if they have that, they should give the patient a copy. Otherwise, it's best to get a pre-approval letter directly from the insurance company. But I know hindsight is always 20/20.
No matter what, I'm really sorry for your friend. That is a hard position to be in, especially when she was clearly mislead by the clinic.
ETA: Can they see if the DH's insurance will cover any part of it since he has the diagnosis? Just an idea...
Also, here's a link that I found about state laws for insurance coverage for IF. Basically, I would tell her to do some research to see what her options are.
https://www.ncsl.org/issues-research/health/insurance-coverage-for-infertility-laws.aspx
I don't want to sound heartless because both IF and $50K in bills are huge issues, but it seems plausible. Your friend is the insured party and she does not have a diagnosis of IF. Therefore, the insurance is not going to want to cover a procedure for someone without a diagnosis. The insurance company likely said during the phone consult that nothing said on the phone is a gurantee of coverage. Additionally, your friend likely signed something at the clinic that states that she is responsible for the financial charges in the event that the insurance claim is rejected. All of those factors may have combined for a whole lot of bad news. I would hope that the clinic would work with her to try to re-code the procedure if they identified any IF issues on her end so that it could be covered. Best of luck to her.
thanks for your response. i will suggest that she try to work something out to lower the balance if she ends up having to pay fully OOP. i'm fairly certain she signed something indicating she was fully responsible for any charges regardless of whether insurance paid or not, that's usually standard procedure. additionally, her insurance company told her that while IVF is a covered procedure on her plan, there was never clarification that it was only covered if SHE was the one with the IF diagnosis. perhaps this is her responsibility to determine? but they also would not give her a pre-treatment approval. she asked, they said no. have you gotten pre-approval letters in the past?
ugh, this is such a difficult time for her. i am going to share all this advice with her b/c she's just so distraught it's hard to think about what to do next.
no, you are right! i'm sure she signed such paperwork. that's pretty standard. unfortunately, she, like many others do every day, took her clinics word for it when they confirmed with her insurance provider that IVF was covered on her plan. i kind of think that a clinic in this line of business should have known to confirm that it was covered in the event that the problem isn't hers, the insured. i mean, this can't be the first time they've had such a client. makes me give them the side-eye.
the doctor's office did determine that IVF was a covered treatment in her plan. they just didn't specify that she did not have an IF diagnosis, that instead the diagnosis was male factor, the male being her uninsured DH.
Well, I have to wonder about the clinic honestly. I did IF treatments and at my clinic they have people whose sole job it is to figure out what your coverage is (and then they send you a letter telling you about it). However, I still made no fewer than a dozen phone calls myself to my insurance company during our TTC process to find out what was covered under my plan. Agree that she also probably signed something saying she is responsible for what insurance doesn't cover. Does she have anything in writing from the clinic telling her what was covered? Did she have any testing done at all? Sometimes "unexplained infertility" is a valid IF diagnosis when they can't find anything obviously wrong (blocked tube, prematurely aged eggs, etc.) MFI would be a double whammy, but it doesn't have to be him or nothing.
If she didn't have a diagnosis herself, I can't fault the insurance company for denying the claims. Yes, it's her husband and if he has issues it's damn hard for her to get PG, but he isn't insured on their policy.
I guess in this case I would fault the clinic primarily for not really figuring out the coverage of her plan, but also her for not doing her own research. It shouldn't be this way, but these days you really have to be your own advocate and be well informed as far as insurance is concerned. Are they willing to work with her at all on the cost? She might be able to appeal the denial with her insurance, but again, if he's not insured they probably couldn't give two shiits.
ETA: I just reread and I give an even bigger side eye to the clinic if (as your post states) she did clomid and then they just jumped right to IVF because of low count and motility issues with no further testing on her (unless his counts were abysmally bad). DH had those exact issues himself and we succeeded with IUI using Clomid and injectibles. But based on his counts, the little "handy chart" my OB used said we should go straight to IVF, so....
did she go for IVF #2 before the IF clinic resubmitted the paperwork under a new code? That's what it sounded like to me, but I may be misunderstanding.
I feel really bad for her and I hope she can get it resolved and get pregnant!
they did a cycle of IUI between the clomid and IVF. due to her DH's diagnosis, the IUI wasn't expected to work, but they did try that before IVF.
I agree about the clinic, that's why i asked here. it seems to me that unless they just opened up for patients yesterday, this should have been a red flag in her coverage. i understand this is in patient responsibility territory, but it seems that if the clinic wants to get paid, they might take more of an interest in whether their patient has the ability to pay.
i've shared the suggestions in this thread with her. hopefully something will make a difference. i know she had some early on questions about ovulation (was having a regular AF, but some anovulatory cycles), so perhaps there can be a diagnosis that will cover her.
yes. as i understand it, she was at the clinic to begin the second cycle when she learned that the first cycle had been rejected by insurance. she called insurance (while still there) and insurance confirmed coverage, but said the clinic had coded the claim incorrectly. assured that it was a clerical error, she went ahead with IVF #2. then after the transfer, learned that the claim had been rejected for two reasons: 1) insurance needed verification that other, less $$ treatments had been exhausted (they did clomid, then IUI, not sure what else is possible, but i think this is satisfied) and 2) the diagnosis was her uninsured DH's.