Insurance coverage ranges from nonexistent to comprehensive. Each insurance company offers many different plans, and each plan has different policies regarding fertility coverage.
Understanding insurance benefits can be confusing for many people, especially when exploring fertility coverage. In most cases, those patients fortunate enough to have fertility coverage with their insurance plan are limited to a certain dollar amount or number of treatment cycles. It is important to review your insurance plan and make sure you understand what is paid for and what it is not. Always follow the guidelines regarding referrals and filing claims to guarantee the maximum allowable benefits.
To help you understand and anticipate any benefit difficulties that you may encounter, please review this document.
Insurance coverage in fertility care is not as straightforward as in most other areas; for example:
- Many times there is coverage for testing to determine why you are infertile, but no coverage for treatment.
- Many times payment depends on why the service was performed.
- Many times the information we get from your insurer over the phone is incorrect or incomplete.
To best serve you, we have developed this approach:
When you become a patient at Kofinas Fertility Group, we contact your insurance company to obtain information regarding the coverage you have for fertility care. We have developed a list of questions that we ask in order to understand the nature and extent of your coverage.
Unfortunately, this “verification” of benefits does not oblige insurers to pay. Insurance companies protect themselves by stating that verification of your insurance coverage by them is not a guarantee of:
- Payment
- What is actually covered and not covered
Because of this disclaimer, even when they have told you or us that a service is covered, there is no obligation for them to pay. The true determination of whether a service is covered is made at the time the claim is received by the insurance company. Whether insurance will pay is dependent on whether:
- The service you received is covered by your plan
- The reason for the service (the diagnosis) is covered by your plan
- The appropriate deductibles and co-pays have been met
- “Preexisting condition” exclusions apply
Further complicating payment, some plans require that:
- You have experienced infertility for a specified amount of time before services will be covered
- The infertility is not due to prior elective sterilization
- Certain treatment steps should be taken before other treatment steps will be covered. This may not always be consistent with the treatment plan that we believe is best for you. For instance, some companies will pay for IVF treatment, but only after three tries of gonadotropin cycles have failed.
There may be occurrences where your insurance company denies payment and deems that a service “is not consistent with the diagnosis” assigned to you.
Claims Filing
- We will be happy to file a claim for coverage of rendered services with your insurance company. Your plan must provide benefits for the service provided for the reason it was provided, and there must be no other restrictions on covered services of which we are aware. We will collect any required co-insurance at the time of your visit.
- Occasionally, when the doctors review lab results, they determine that another test is needed to make a complete evaluation. When this occurs, the charges for the additional test will be posted to your account at the time test is ordered.
- Occasionally, our audits detect that services were incorrectly posted to your account, resulting in overcharges or undercharges. When we identify such errors, we will correct your account, resulting in a credit or balance.
As discussed prior, there are times when insurance companies process a claim in a manner different than expected. In these cases, be aware of the following:
- A claim may be completely denied with no payment made, which makes you entirely responsible for the charge.
- A claim may pay differently than was anticipated, which also makes you responsible for a larger portion of the charge than expected.
Even though your insurance company communicated to us and we in turn communicated to you that a given service or set of services is covered, this IS NOT A GUARANTEE BY US of your insurance company’s coverage for that service or set of services. If your insurance company denies coverage for any reason, you are responsible for full payment of the services billed. Because the insurance company states that the verbal information they provide is not a guarantee of payment nor can it be relied on as a guarantee of coverage, we are not responsible for any statement made by your insurance company, nor any statement made by us to you based on information given to us by your insurance company. It is very important for you to understand that the only TRUE representation of whether a given service is covered is when your insurance company actually processes the claim.
When a claim is denied, we will first try to understand why: Was the claim processed correctly? Were the appropriate diagnoses used? Were benefits incorrectly stated to us at verification? Typically an insurance company will send an EOB (“Explanation of Benefits”) that outlines what they paid and didn’t pay and why. If we believe there are errors in the claim, we will resubmit.
However, if there are no errors, then we will make the corresponding adjustment to your account, determine the portion of the charge you are responsible for, and post this portion to your account.
As stated previously, there are times when an insurance company states that the test or procedure performed is not consistent with the diagnosis assigned to you. The practitioners at the Kofinas Fertility Group order services to be performed when they determine that they are important in the diagnosis and treatment of the patient for the particular circumstances of the patient. When your insurance company denies payment and renders the decision that the services are “not consistent with the diagnosis,” it has decided otherwise.
When services have been ordered and/or performed by a Kofinas Fertility Group practitioner, and your insurance deems the services to be “inconsistent with the diagnosis,” your practitioner has deemed them to be important in your diagnosis and treatment and for your particular circumstances. You will be responsible for the payment for these, should your insurance company deny payment and state that these services are “inconsistent with the diagnosis” assigned to you.
There are instances of charges being generated or recognized on days when there is no office visit scheduled. With the very busy lives of our patients, it is difficult to reach each patient to come in and settle balances as they arise. Therefore, it is our office’s policy to require a credit card authorization be maintained on file so that your balances can be settled as they occur. Our patients find this convenient.
When these cases arise:
- We will call you before making any charge in excess of $500.
- We will call you before making any charges to a debit card, regardless of amount.
- We will call you before making any charge for a service provided more than 6 months ago.
- We will mail you a copy of your credit card receipt and your statement on the day the charge is made.
- An authorization form will be supplied to you and your spouse for your signatures.
Outside labs may be used for necessary testing. You will receive a statement from that lab, which you will be responsible for paying.
Insurance companies often perform audits of paid claims. These audits can be performed for up to two years from the latter of the following: (a) the date of service, (b) the receipt of the claim, (c) the payment of the claim, or (d) the receipt of an appeal. When an insurance company performs an audit and determined that claims were paid in error and should not have been, the insurance company contacts us for a refund of the monies they paid. They then direct us to collect for these services from the patient. Unfortunately this may mean that for a period of up to two years after any one of the above listed events, your insurance company may reverse their decision. If this should occur, we will then contact you for payment for these services.
Should you have an outstanding balance on your account that is your responsibility and that is greater than 30 days old, we will assess simple interest on the unpaid balance at the rate of 1% per month. This represents an annual interest rate of 12%.
When your co-pay, co-insurance or patient responsibility balance for the day’s visit is not paid at the time of service delivery, we will assess a $25.00 administrative billing fee and subsequently bill you for the unpaid amount.
Unfortunately, managing insurance benefits is often troublesome in fertility medicine. For more information about our insurance policy, or to request an appointment, call 212-878-7677. You can also schedule an appointment using our easy online form.
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