Health Care Coverage for Reproductive Immunology
What the Doctor’s Office Will and Will Not Do for You
With the high cost of health care everyone is concerned with what insurance companies are willing to pay for services. Most couples do not know what their insurance company will pay for a particular problem, if in fact they will pay anything at all. The advent of managed care has elevated this concern for couples who are afflicted with reproductive problems, not to mention reproductive problems that are immunologically based. Insurance companies generally define a covered expense as a reasonable expense incurred by a covered person for any of the services or supplies that are medically necessary for treatment of an illness or a disability. “Necessary” ordinarily means consistent with currently accepted medical practice, and generally insurers reserve the right to determine reasonable and customary charges for medical treatment. This is the amount on which they base their payment. This reasonable and customary amount declared by the insurance company may be far less than the amount charged the couple.
In addition, insurance companies typically will not deem a medical service, supply, treatment or expense as being necessary if it is experimental in nature. They generally consider a service to be experimental if it meets at least one of these conditions:
- It is within the research or experimental stage;
- It involves the use of a drug or substance that has not been approved by the United States Food and Drug Administration, by issuance of a New Drug Application or other formal approval;
- It is not in general use by qualified physicians or;
- It is not of demonstrated value for the diagnosis or treatment of sickness or injury.
An insurance company will often determine that a treatment is experimental and therefore not to be a covered expense and leave the burden on the couple to convince them otherwise. Not all couples have the energy, ability or resources to perform this very time consuming process.
In many cases the amount of compensation one gets is determined by how much the insurance company is willing to pay, if anything. Many cases involving immunology of infertility and recurrent pregnancy losses are not clear cut and the amount reimbursed is a function of the policy holder’s ability to battle the insurance company. Today, much emphasis is being placed on health care reform and on comparing health care and covered expenses in the United States with other countries. Most couples working for a living are now in a managed care program that further limits their options especially if they are living in a state that does not mandate coverage for infertility. This is an important topic for everyone on a long and disappointing journey toward parenthood. It raises lots of concerns about what would be considered a necessary treatment, and what would be the corresponding level of reimbursement for the service.
Health insurance companies are in the business of managing risk. They understand the elements of uncertainty and risk, and have sophisticated techniques available to manage risk to remain profitable. They are also obligated to reimburse their policy holders for necessary medical treatment. Couples afflicted with infertility or pregnancy loss, struggling with reimbursement problems soon begin to realize that tests and procedures necessary for them to realize the important “family value” of becoming parents may not be viewed as necessary medical treatment by most providers.
The following guidelines for the consumer should provide some help on what needs to be done by the couple, what needs to be done by the primary care physician and what needs to be done by the Reproductive Immunology facility providing consultative services to determine, many times pre-determine, what tests and treatments will be covered. In a survey published by us from experience in 1993-94, prior to the advent of managed care to the degree we see today, we found that 80% of couples had insurance claims initially denied for Reproductive Immunology services. For the couples who took further action and appealed the denial, most received coverage. With the marked increase in couples now enrolled in managed care programs, there is increasing difficulty in reaching this goal.
We are not there yet and the consumers voices must be heard. Most work for a living and buy health benefits in order to one day experience the joy of becoming parents. The majority of those afflicted with infertility and recurrent pregnancy losses are denied this option, unless they pay for it out of pocket. In a nation committed to strengthening family values, is this type of denial justified?
What the Doctor’s Office Will do for You
- If your claim is denied, send your claim to the physician’s office and they will first send a letter of medical necessity, geared to the individual patient, to the insurance company. Often this is all the insurance company needs. Please note, you will be charged $50 (USD) for letters of medical necessity as the record is abstracted by a physician’s assistant and the letter is drafted on an individual basis. You will also be charged $75 (USD) for appeal packets due to copying costs and the length of time it takes the physician’s staff to assemble packet.
- The physician’s office will provide you, at your request, a statement and/or detailed account inquiry. An account inquiry is a detailed statement that outlines all charges and payment information. These items can be obtained from Chris Sanow at (408) 356-9500.
What the Doctor’s Office Will Not do for You
- The physician’s office will not accept insurance only for services rendered for any patient.
- The physician’s office will not argue or defend reasonable and customary charges with your insurance company.
- Deductibles must be met before insurance payment starts.
- Patients do have financial responsibility to pay.
- The physician’s office will not fax records to patients. This stops all work in the office. Patients need to know that the physician’s office needs time to respond to insurance inquiries; They for two week turn around for this to be accomplished. The average turn around time for the insurance company is 2 months.