Insurance coverage - how strange

[ybc]

I just discovered this, and it's all very strange. I have two insurances, my primary doesn't cover any IF related testing and treatment, but my secondary does. Since my secondary insurance does, so everything is itemized. Now the thing with primary/secondary insurance is that you have to file with primary insurance first for everything before it's filed with secondary (thankfully, the clinic did all that). Now to my surprise, my primary insurance so far has covered a lot of things - blood testing, ultrasound monitoring, etc. I haven't started stim yet, so don't know when my primary will start to reject. The reason that I knew that my primary insurance doesn't cover ANYTHING related to IF is that two years ago I had a HSG procedure, and they refused to cover it.

Had it not been this strange arrangement (primary/secondary insurance), I wouldn't have found this out. I bet that a lot of individual items that are incurred during IVF is actually covered except that clinics don't want to deal with paperwork? So they have cash prices? I will find out once I go through one cycle exactly what is not covered by an insurance that doesn't cover IF.

[zincchick]

ybc,
I'm finding similar information. Speaking with my insurance co. last week, I discovered that we've only used <$5,000 of our $50,000 lifetime benefit. I didn't understand how, after 2 IVF's that could be! Turns out, all the U/S, bloodwork and many of the appointments are covered as regular stuff. Only a small portion of what we're doing (i.e. retrievals, anesthesia, etc) falls under the category of IVF for their purposes.

Where the insurance co. is getting us is on the meds. We have a maximum $5,000/yr coverage. After that, it is all out of pocket. And that seems to be where most of the $ goes. The $50,000 lifetime benefit sounds great, until you dig into the details of the coverage and realize it's pretty much nonsense. You have to put in so much more of your own $ to get anywhere close to that in coverage.

I don't fully understand how the insurance companies work and how they are defining things. It's quite confusing.

[pbcolor]

You are so right. It is all tied to the diagnosis and procedure codes that each procedure is billed under. If you don;t have infertlity coverage, certain procedures can be bileld under a "gyn", fibroid or other diagnosis codes and be 100% covered. the infertlity diagnosis codes are 628.0-628.9. The same procedure code i.e a fluid ultrasound, could be disallowed under infertility adn allowed under unexplaind gyn pain or uterine myoma (fibroids)

The good thing is that all insurance companies have clinical policy bulletins for all areas of medical coverage posted on their information webistes. So you can check in advacne what is and is not covered and not covered.

I have found that I have to learn each of the key diagnoses that my doc bills under and get a list of the procedure codes. They are ususally on their super bills. And I only know 1 clinic that doesn;t provide the patient with copies of their super bill with the codes; That's SIRM.. and they are a billing nightmare.

As far as the meds are concerned. I highly recommend, saving your insurance for the cycles and getting the most costly portion of the meds (stim meds- follistim/menopur/bravelle) from free garage sale dot com. It will save you thousands.. and you can often get away with a cycle's worht of meds for around $1500 or less. While they will suck up $5-$7K of insurance benefits each cycle



In

[ybc]

Funny you said that SIRM is a billing nightmare -- they haven't billed my insurance for my feb surgery yet! I emailed them twice, but obviously they should bill to get paid.

Thanks for other tips regarding insurance. It's kind of sad that we now know insurance billing codes, isn't it?