While advocacy has always been a priority, our doctors have recently become compelled to help our patients fight insurance denials.
At the Institute for Reproductive Medicine and Science, we’re committed to helping our patients realize their dreams of growing their families. Often our assistance extends beyond medical treatment.
Recently, Dr. Debbra Keegan, a reproductive endocrinologist and IRMS’ Clinical Director, treated a New Jersey couple who had experienced recurrent pregnancy loss. Deanna and Jon Harkel had suffered two miscarriages when they first met Dr. Keegan, and experienced another miscarriage shortly thereafter.
“Miscarriage itself is not uncommon but having three consecutive miscarriages only happens to approximately 1% of reproductive age women,” said Dr. Keegan. “After Deanna’s third miscarriage, I recommended IVF with PGT because chromosomally abnormal embryos is the #1 reason for miscarriage.”
However, the preimplantation genetic test (which allows the embryologists to choose the healthiest embryo and enhance the chances for a viable pregnancy) was not approved by the Harkel’s insurance company – even though her insurance covers it.
The insurance company, Horizon, denied the Harkel’s claim because they said they needed to try less expensive options such as IUI (intra uterine insemination) first. The couple proceeded with an IUI cycle and suffered a fourth miscarriage.
At that point, Dr. Keegan joined the couple’s second formal appeal, appearing with them before a panel at Horizon’s headquarters in Newark to argue why pre-implantation genetic testing was the right choice.
“This was the next logical step after four consecutive miscarriages, but they denied us again,” said Dr. Keegan. “The first time they said it was medically unnecessary. After our in-person appeal, they said we were requesting procedures that were ‘experimental.’ It seemed very subjective to me, particularly because they changed the reasoning for each denial. The kicker in her being denied coverage a second time is she will not be able to request authorization for these procedures for a full year from the denial date.”
Undeterred, Dr. Keegan and the Harkels appealed their case again, this time taking it to the New Jersey State Department of Banking and Insurance – and they won. The preimplantation genetic testing was deemed medically necessary given the couple’s history of miscarriage and Horizon’s denial of coverage was overturned. The Harkel’s have now begun an IVF cycle with Dr. Keegan.
Unfortunately, it’s not unusual for the doctors at IRMS to see insurance companies deny coverage for in vitro fertilization for recurrent pregnancy loss, even if the patient’s plan covers it.
“It is disheartening to say the least to watch insurance companies subjectively deny a patient’s coverage while she’s still paying for it,” said Dr. Keegan. “I even did a cost analysis to demonstrate how much Horizon had already spent on her doing IUIs and what they were proposing to spend, versus what they would have spent if they just gave her the IVF cycle to begin with. It was much more. So I don’t understand their medical or financial reasoning.”
While advocating for patients has always been a priority at IRMS, our doctors have recently become compelled to take on a more hands-on approach when it comes to insurance denials.
“Advocacy has always played a big part in our practice,” said Dr. Keegan. “One of the issues, however, is in order to participate in this level of advocacy we need to be out of the office and therefore not seeing the very patients we are trying to treat. The way the system works really needs to change.”
Until insurance denials become less common, IRMS doctors will continue to fight for their patients’ coverage. Dr. Serena H. Chen recently attended an appeal of Horizon Blue Cross Blue Shield of New Jersey’s denial on behalf of a patient with recurrent pregnancy loss who had been told that she must first try IUI before attempting IVF.
Meanwhile, Dr. Keegan is currently advocating for a single 35-year-old woman who has benefits for egg freezing, but her insurance company won’t cover it until she first tries to conceive for six months. “It’s a form of discrimination,” said Dr. Keegan. “She can’t utilize the coverage she’s been paying for because she hasn’t satisfied an outdated definition of infertility. So, we’ve got a way to go before many get the coverage they are entitled to.”
If you are considering fertility treatments, Dr. Keegan suggests you:
- Talk to your HR department and insurance company first to determine exactly what your coverage entails.
- Don’t be shy about using the coverage you have. Some insurance companies offer a “lifetime maximum,” allowing you to spend it how you see fit.
- Use a fertility practice like IRMS that pairs each patient with a financial coordinator who will help you navigate your benefits to ensure you get all the coverage you are entitled to.
- Point out to your boss that companies like Apple, Facebook, Google, Netflix, eBay and Spotify now cover procedures like egg freezing, and there is a movement among cutting-edge brands to advocate for their female employee’ reproductive autonomy.
Most importantly, if you find yourself at odds with your insurance company about getting the coverage you are entitled to, don’t lose hope.
“Don’t give up the fight because I think the pendulum is swinging in the direction in favor of patients,” said Dr. Keegan.
If you’re struggling with infertility and have questions about your insurance policy, give us a call at 973.548.9900 today.