Insurance Helpful Hints

  1. Treatment for Asherman's Syndrome should not be coded as Infertility.

    Asherman's Syndrome - Code 621.5
    Amenorrhea - Code 626.1 
    oligo/hypomenorrhea - Code 626.1

    Infertility itself is coded as 628.9 - Make sure you are NOT coded for infertility as Ashermans is not a matter of infertility.
  2. If you have more than one option for insurance, read the fine print, check the details of coverage closely, call with questions, then pick:

     I work at 2 places and am eligible for insurance coverage at both places. When I wanted to go to an out of network provider for my primary insurance, I obtained secondary insurance that would cover the other provider at my second place of employment and I made sure that all of my doctors were covered by either the primary or secondary insurance. I picked the high coverage option for my secondary insurance because it covers inpatient maternity care 100%. I may never use it, but if I'm lucky enough get pregnant I will be high risk and costs for inpatient care for a high risk pregnancy or premature baby can really add up. Once I'm through this mess I will drop one of the insurance companies, but for now I have more than made up the double premiums.

     My primary insurance covers 50% of the cost of fertility drugs and only from a single provider; my secondary insurance covers 75% of the cost of fertility drugs and offers a choice of providers. For an expensive drug 50% versus 75% can add right up. None of the other insurance plans available to me this year offered any coverage for fertility drugs.

     I picked the high coverage option for my secondary insurance. As I recall, the low coverage option had a higher co-pay for drugs based on a % of the cost of the drug (e.g., 25%) and they may have excluded fertility drugs altogether. 

     During my first month of fertility treatment I had insurance that covered fertility drugs 100% but only if they weren't used in conjunction with fertility treatment which meant IVF or intrauterine insemination. I passed on the intrauterine insemination that month. Maybe it decreased my chances a bit, but I'd just had surgery to open everything up so I figured if there was ever a time to pass on IUI, that was it.
  3. Read your bills closely, ask for itemized statements, keep all of the paperwork you get.

     I was billed for pre-op care for a hysterectomy I never had. I had copies of the email I sent to the MD canceling the surgery. I saved $1000.
  4. Make sure your referrals are processed according to your insurance company rules. Call your insurance company if you think you have been billed wrongly.

     My primary care physician referred me for a colonoscopy so it should have been covered. I called the insurance company and they said they had never received a copy of the referral from the primary care MD. I had the primary care MD send it another 2 or 3 times, but finally the insurance company got it and I saved several hundred dollars.

     I verified precertification for an MRI but was then billed for it by the hospital after the insurance company turned it down. I called my insurance company, it turned out the hospital hadn't processed the claim correctly and they were responsible for the bill, not me. I saved over $1000.

     I was billed for a variety of physicians visits that my secondary insurance rejected because they never received the EOB (evidence of billing) from the primary insurance company. The hospital had never submitted the bills to the primary insurance. I asked them to submit the resubmit the bill along with the EOB, I ended up owing $7 per visit instead of $100.

     I got billed for $1300 for surgery that should have been covered 100% by my secondary insurance. I called my insurance company, they informed me the hospital hadn’t submitted the bill in a timely fashion. I called the billing office told them what my insurance company had told me and they took it off my bill. I saved $1300.

     I will save nearly $2000 on fertility drugs because I got my primary insurance to send me a letter telling me my prescription was not covered because it was from an out-of-network provider. With the documentation of denial of coverage by my primary insurance, my secondary insurance will now cover the medication. Initially the primary insurance refused to give that documentation to me ("we don't process prescriptions from doctors at XXX hospital" "it's not my job" etc.) then they gave me a generic statement ("we don't cover fertility medications from doctors outside YYY hospital), neither of which would have been satisfied the secondary insurance company. I had to talk with the supervisor’ supervisor to get my documentation. I made sure to request authorization before picking up the drug. But I only knew to do all of that because I called the secondary insurance company and asked what documentation was needed.
  5. Know your coverage:

     I was billed full price for a variety of services (e.g., surgery). My primary insurance says I owe the balance of whatever the out of network provider wants to charge. However, my secondary insurance has a negotiated rate for those services with that particular provider (and the negotiated rate is halfr even less of full price). I mentioned that to the billing office and over $1000 was taken off of my bill.
  6. Request an itemized bill and use it to track what has been paid for by whom:

     I wouldn't have been able to figure out most of the above examples without the itemized bills. But, I had to request the itemized bills specifically from one of my providers. The other providers bills are fairly straightforward to follow.
  7. Ask to speak with a supervisor if you aren't getting anywhere and then continue to interface with that person over time.

     I was billed for several visits that either had not been sent to my secondary insurance at all or were sent to my secondary insurance before my primary insurance and were therefore rejected. I spoke with 3 different people all of whom said they would fix and did not. I finally spoke with a supervisor, and after 3 conversations with her over a 2 month period and a certified letter, the problem was corrected.

     On two occasions I've been sent to collections for less than $100. On both occasions I contacted the supervisor I'd been working with and they put a hold on it. I sent a certified letter to the collection agency as well. In both cases, the bill was straightened out in my favor.
  8. Ask for itemized cost estimates of your treatment.

     One fertility center advertised that with XYZ insurance plan, once you pay the the copay (which you find out in the fine print is $1000) then all doctor and hospital treatment is covered and 50% of the drug costs are covered. When I requested an itemized pricing of the charges for the treatment I would receive it added up to $1400 and the drugs at 50% cost to me would be $1000-1500. At the cross town competitors, the itemized charges added up to $1200 and the drugs at 25% cost via my secondary insurance would be $500-750. So, even if I paid out of pocket for the doctor and hospital treatment at the cross-town competitor, I only paid $50 more than I would end up paying at Fertility Center 1 with insurance.
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