Financial Considerations Associated With Infertility Treatment
Many patients have questions about the financial issues associated with infertility treatment. Some of those questions include:
- How much does it cost?
- Will I be able to afford it?
- Do I have insurance coverage for the service(s) I need?
- How do I get answers about my insurance coverage?
- What if my insurer won’t pay for some or all of the services I need?
Any or all of these issues can add significant stress to the existing stress of dealing with issues of infertility. At IRMS, we understand this and, therefore, we work to make the financial and insurance process as straight-forward and patient-friendly as possible.
Each patient at IRMS has their own financial coordinator, who will work with them to address the payment-related issues, including insurance benefits, pre-authorizations, and other payment arrangements. In addition to meeting the physician and other clinical staff during the first visit, our patients also meet with their financial coordinator to review the costs/insurance issues related to their specific treatment needs. Of course, our coordinators are also available to assist if financial or insurance issues arise at any time during the course of the treatment process.
INSURANCE CAN BE COMPLICATED AND CONFUSING
At IRMS, we recognize that working with insurance coverage can be a complicated and confusing issue. In most business transactions, there are only two parties—the buyer and the seller. However, in health care, there is the buyer (the patient), the seller (the provider/doctor), and the payer (the insurance company). This makes the process more complex because in order for the buyer to receive maximum benefit and the seller to receive payment, the payer’s rules must be followed. Unfortunately, every payer has different rules and guidelines and even an individual payer can have multiple different plans—each with different requirements and coverage levels. Our experienced Financial Coordinators do their best to be familiar with the insurance coverage and plans, but your assistance in obtaining as much information as possible about your plan is very helpful.
In this process, it is IRMS’ objective and mission to be ethical in its dealings with both our patients and insurers. Therefore, we have established the following protocol for determining benefits and payment requirements for our patients.
- As soon as we are notified of a patient’s intent to receive services, we will contact the patient’s insurer(s) to obtain a benefit quote.
- Based on that benefit quote, we will determine the patient’s financial responsibility, whether that be copayments, deductibles, or payment for the full amount if benefits do not exist for the services provided. Payment of the amount determined is due two weeks prior to the beginning of the cycle start.
- We will bill insurers for all services provided. If the insurer makes payment for services that are not consistent with the benefit quote originally received, we will contact the insurer to be certain that the benefit payment is correct. If it is correct (and the benefit quote was incorrect) we will promptly refund any patient overpayment. If the payment is not correct, we will return the payment to the insurer.
Our objective is for you to obtain every penny of benefit to which you are entitled, but we have a contractual obligation with the insurers to not accept incorrect benefit payments.
IRMS Participation with Specific Insurers
Currently, IRMS is a participating provider with the following insurers:
- Tricare- authorized provider
- United Health Care
If your insurer is not in the list above, we will be happy to check with your insurer to see if you have “out-of-network” benefits.
Please note: IRMS does not participate with any Medicare or Medicaid insurance plans.
INFORMATION ABOUT YOUR INSURANCE POLICY
Actual Contract and Summary Plan Description
Insurance policies come in two forms: the actual contract and the summary plan description.
The summary plan description is a brief summary of medical benefits and is usually provided when you enroll in an insurance plan. You will need to request a copy of the actual contract and can obtain this information from the employer who issued the contract or from your insurance company or agent.
The summary plan description provides a general explanation of your plan and benefits. It will let you know whether you are enrolled in HMO, PPO or indemnity coverage. In general, HMOs are the least costly plans and have more limited coverage. It is important to look carefully at the benefits your employer provides at open enrollment and consider changing companies to get the best benefits for fertility.
If you are able to get a copy of the contract, then the next step is determining how your insurer defines infertility as different insurers have different definitions.
For example, your insurer may consider infertility to be 12 months of attempted conception. However, if you have irregular or absent menstrual cycles, it would not be reasonable to attempt conception for 12 months if you are not ovulating regularly. Instead, you may consider seeking treatment for irregular cycles initially to determine if there are hormonal reasons why menses are not regular.
Questions to Consider
Below are other insurance questions that you should consider before seeking treatment.
- What type of coverage is listed?
- Which procedures require preauthorization? Does preauthorization need to be done for each cycle of treatment and how long does it take to get?
- Are there restrictions on the type of healthcare provider who can perform infertility services?
- Are there limits to the number of procedures or the maximum dollar limit on benefits? For example, some patients are limited to three treatment cycles of any type, including IVF, compared to the more common limitation of three or six cycles of IUI and one or three cycles of IVF. It is also important to know if the maximum dollar benefit is lifetime or annual. Some policies have limits on the age of the female patient or the number of months of treatment.
- Is there a co-payment for medical services?
You should also examine your insurer’s prescription drug plan as fertility medications are often very costly. It is important to understand your drug benefits prior to starting any treatment. First, you should find out if you have drug coverage. Next, determine if fertility drugs are covered under your prescription plan. You may want to consider the questions below before starting fertility treatment.
- Is there a co-payment for drug coverage?
- Is prior authorization needed for these medications?
- Does my plan cover self-administered subcutaneous (under the skin) or oral medications?
- Are there discounts for mail-order medications?
- Are any of the drugs on the prescription formulary and therefore covered?
Before visiting a fertility specialist or having a treatment cycle, please have the following information:
- The name of your insurer
- Your policy identification number
- The insurance company patient representative or contact person
- The insurance company phone and fax numbers
- The insurance company e-mail address and Web site
NOTE: Communicate with your insurance company in writing so you have documentation if any claim disputes arise. Get a commitment of coverage for a specific medical service before you start treatment, called preauthorization or predetermination. You should contact your insurer in writing and request a written determination of your exact coverage amount prior to receiving any procedure. When writing a letter to your insurer, it is helpful to include the following:
- Group and ID numbers (patient insurance identification number)
- Name of treatment(s) and/or medication(s)
- Reason for needing the procedure/treatment/medication
- Below is a list of questions you may want to ask your insurer.
- Will the treatment/procedure/medication be covered under my current coverage or under my major medical portion?
- If yes, is there any limit of any kind-dollar amount or number of attempts?
- If no, are any portions of the charges covered for prescription medication, laboratory tests or ultrasounds leading up to the intrauterine insemination?
- If none of the charges are payable, please identify the page in my contract where all of the charges are specifically excluded.
PATIENT FINANCIAL RESPONSIBILITY
For the convenience of our patients, IRMS accepts cash, personal checks, money orders, as well as Visa, Mastercard, Discover, and American Express. Our financial coordinators can answer any questions related to your payment and financing options.
Financial coordinators can be reached Monday through Friday, 8:30 a.m. – 4:30 p.m. at (973) 322-8948.
New Jersey Insurance/ The Family Building Act:
The Family Building Act requires insurance policies that cover more than 50 people and provides pregnancy-related benefits to cover the cost of the diagnosis and treatment of infertility. The law defines infertility as the disease or condition that results in the inability to get pregnant after two years of unprotected sex (female partner under the age of 35) or one year of unprotected sex (female partner over the age of 35) or the inability to carry a pregnancy to term.
Coverage includes, but is not limited to:
- Diagnosis & diagnostic tests
- In vitro fertilization (IVF)
- Embryo transfer
- Artificial insemination
- Gamete intra fallopian transfer (GIFT)
- Zygote intra fallopian transfer (ZIFT)
- Intracytoplasmic Sperm Injection (ICSI)
- Four completed egg retrievals per lifetime
Coverage for IVF, GIFT and ZIFT is required only if:
- The patient has used all reasonable, less expensive and medically appropriate treatments and is still unable to get pregnant or carry a pregnancy.
- The patient has not reached the maximum number of allowed egg retrievals and the patient is 45 years of age or younger.
- The procedures are performed at facilities that conform to standards set by the American Society for Reproductive Medicine or the American College of Obstetricians and Gynecologists.
The law allows religious organizations to request an exclusion of this coverage if it is contrary to the religious employer’s bona fide religious tenets. (New Jersey Permanent Statutes: 17B:27-46.1X Group Health Insurance Policies; 17:48A-7W Medical Service Corporations; 17:48-6X Hospital Service Corporations; 17:48E-35.22 Health Service Corporations; 26:2J-4.23 Health Maintenance Organizations)