We are contracted with many insurance programs.

Insurance coverage and reimbursement issues for the treatment of infertility are complex. There are many variables that come into play in determining how much support, if any, these companies will provide.

The first question we are typically asked by a prospective patient is “Are you in my network?” We have stopped giving a direct “Yes/No” response because, unfortunately, such a simplistic answer misleads so many patients. Unlike the answer your primary care physician can give regarding being in or out of network, the infertility practice’s answer is much more complex. You may wonder, “How can telling a patient whether you are in their network end up misleading them?” Here’s what happens.

In assisting our patients we have seen that the vast majority of insurance plans fall into one of three categories when it comes to infertility coverage.

1.) The plan provides no coverage whatsoever for infertility services.
Thus, it really does not matter whether you see an infertility specialist in or out of network, because no infertility services are covered. This means that even if you go to an in-network physician who provides infertility services to you, you will still be self-pay, because the service itself is not a “covered benefit.”

In this circumstance, even though a practice may be in-network to you, you will be responsible for payment in full, since your insurance company will not reimburse for the services themselves. Identically, if the practice is out-of-network for you, you will also be responsible for payment in full at the time of each visit.

As you can see, in this situation, there is no difference in being in or out   of network, if your particular insurance plan does not provide coverage for infertility services.

2.) The plan provides coverage only for the diagnostic phase of infertility service.

In this scenario, the insurance plan will typically cover services rendered to determine:

that infertility does in fact exist, and that if it does, the nature or cause of the infertility.

Once the above questions have been answered, which is at the time the patient is given an infertility diagnosis by the physician, the diagnostic phase has come to an end.

During the diagnostic phase, an in-network office should collect your co-pay and file insurance claims for each visit in this phase. If you are out-of network and have out-of-network benefits for the diagnostic phase, then you should expect to pay for services at each visit. You will then file your insurance claims and receive insurance reimbursement directly. In either case, some level of coverage is provided during this phase.

When the diagnostic phase ends, then no future infertility services are covered by the insurance plan in these cases. Thus, when the treatment phase begins, you will be expected to pay for all services when rendered, whether you are in or out of network

3)  The plan provides coverage for the diagnostic phase and for some infertility treatment services, but not all treatment services. 

In these circumstances, coverage is provided for some methods of infertility treatment, but not others. We have seen situations where oral agents such as Clomid therapy is/is not covered, other ovulation induction using injectable gonadotropins is/is not covered, intrauterine insemination (IUI) is/is not covered, and so on.

Again, whether you are in or out of network will not matter, because what matters is whether the service itself is a covered benefit. Thus, if the service itself is not a covered benefit, even though you see an in-network physician, you will still be self-pay at each visit, just as if you were out-of-network.

(Note: There are some plans that provide insurance benefits for in-network treatment, but not out-of-network treatment.)

So you see, the key question typically is not whether you will be in or out of network at a given infertility center. Rather, the question is whether your plan covers diagnostic infertility services and infertility treatment services. If it covers infertility treatment services, it is important to know which services are specifically covered and which are excluded from being covered.

There are as many combinations of possibilities with these insurance scenarios as there are companies for whom the insurance plans are developed.

Listed below are additional circumstances that we have seen with the various plans with which we have had contact. .

  • Although a plan may cover a particular treatment service, there is a limit as to the number of services, e.g. not more than 3 IUI attempts, not more than 2 lifetime IVF cycles, etc.
  • Oral medications may be covered while injectable medications may not be covered.
  • There may be a maximum dollar amount stated in the policy that can be paid for infertility services, such as a $25,000 lifetime cap.

Keep in mind that there are no two insurance plans that are necessarily alike. The degree to which diagnostic services or treatment services are covered or not covered is strictly dependent on what your employer has purchased as coverage in the policy they obtained for your company.

So – talking with others going through infertility treatment, even talking with someone who is in the same network as you are, is of no use in determining the nature and extent of the coverage in your plan. Even though the other person may be in the same network or have the same insurance company, your two plans may be totally different.

What does this mean for you as an infertility patient? It means the following.

  • Know your insurance plan. Know which infertility services (both in terms of diagnosis and in terms of procedures rendered) are covered and which are not. Understand whether these services are covered in-network only, or whether you have out-of-network benefits for these services. These are such complex issues that we feel it is important that patients take the step of finding out the extent of their coverage before treatment is even initiated. Your physician’s office should certainly be prepared to assist you in navigating this complex maze of information.
  • Do not let the physician’s status as being an “in-network” provider be the determining factor for selecting an infertility center. As you can see from above, there is no simple answer when it comes to insurance and infertility .

Some Other Important Insurance Information

We have had circumstances where patients have questioned whether a visit can be “coded” as something other than infertility, when in fact the infertility diagnosis is the proper one to assign. For example, although a couple’s infertility may be caused by endometriosis, a “covered” service, it would be misrepresentation on our part to state
that we are seeing the patient just for the endometriosis when in actuality we are treating their infertility. Not only is such action unethical, but it also constitutes insurance fraud, which is illegal. Just as we commit to our patients to be honest and forthright, so too are we honest and straightforward with the insurance companies.

Lastly, it is important that you know that your insurance companies have the right to review claims for proper reimbursement for up to one year after the claim is made.
This means that reimbursements that were made in the past for what was communicated by the insurance company as a covered diagnosis or service can be reversed. When this occurs, the insurance company can demand refund reimbursement from you or from the practice, depending on who was paid the benefit. Should an insurance company in the future deny benefits for services rendered in the past and thus request refund of payment to them, the payment for the services becomes the responsibility of the patient. Insurance companies can and will pursue reimbursement from patients and will use any and all means necessary to get these payments including legal action.

Understand your plan – what it covers and what it does not. Make certain that all of your decisions in your infertility treatment process are based on your full understanding of the nature and scope of the related clinical, psychological and financial elements.