3 July 2011

Pursuing Reimbursement for ART Procedures. Part 2

Posted by Jody under: Women's Health .

No matter what kind of outside assistance you receive, its vitally important to fully understand your insurance contract and any benefits which are available to you. You are your best advocate to ensure appropriate coverage. There are sometimes provider and manufacturer resources to assist the physicians business office staff and patient with identifying coverage. Seek these services out whenever they are available. Tracking down insurance benefits and identifying financing options are two more examples of when you want to work with all the individuals participating in your treatment as a team.
When it comes to your coverage, there are several things you should do:
First,you should read your policies and pay particular attention to the list of exclusions. These are the treatments and procedures the insurance company states it will not cover.

Second, if initially denied by insurance company you should ask the insurance company to provide information in writing about coverage for the procedure, or any aspect of the procedure, you require.

It is also crucial that you send a predetermination of benefits letter to your insurance carrier before treatment begins especially if there are any unclear areas in coverage benefits (see the sample letter). Obtain and include an itemized fee schedule from your doctor for the recommended procedure complete with CPT codes, diagnosis codes, and charges. The fee schedule should be broken down into as many components as possible. For example, pre-retrieval charges versus retrieval charges, versus transfer charges. Depending on your health insurance plan, some or all of the costs may be covered. By breaking out and itemizing items in this way you will maximize converage by avoiding “blocking out” of any covered items that may have inadvertently been grouped with items not covered. The letter should also specify the particular procedure required, and any medical reason for the procedure, such as endometriosis, tubal occlusion, or other medical conditions.

Unless there is a specific exclusion in the insurance plan clearly stating that infertility coverage does not exist, patients should not be discouraged if the initial response from the insurance company is unfavorable. If there is vague language, any room for interpretation, or if aspects of your request have been ignored, these may be good indicators that it is in your best interest to escalate your request and push for further clarification and review. Insurers are generally very careful when putting a claim refusal in writing and tend to be sticklers for detail, while a statement may suggest coverage or an aspect of coverage is not available, it is helpful to read between the lines and look closely for omissions -especially when a clear and concise reason for rejection is not provided.

Your support group, medical team, or pharmacy should be asked to review responses from insurance companies and advise you on your options. Staff should be able to advise you on insurance matters, or be able to refer you to a service that can guide you through the insurance maze. Some issues can be resolved by the medical office, but other issues may require an opinion from an attorney knowledgeable in infertility issues and insurance contract language.

At the very least I hope my suggestions will allow you to receive written confirmation of insurance benefits and know exactly what portion of your ART procedure will be covered by insurance. This should be helpful for financial planning and for building a realistic treatment strategy with your team. You will also have the peace of mind of knowing you have done your best to maximize coverage and take control of your fertility drugs costs.

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