Insurance Issues

Not a day goes by here when I am not faced with an insurance issue to address. It still amazes me that insurance companies can take your monthly payments and then go ahead and shut you out in terms of treatment. Clearly not all insurance companies are problematic but I will say that many of them are...

Last year we had very productive discussions with Aetna and they were very open to discussing what we do here and how we do it. Other companies were not at all interested in our views.

Here is a true story: Several years ago I had a patient whose husband was azoospermic - no sperm in the ejaculate. We had arranged for a testicular biopsy with a urologist and had frozen sperm that could be used for IVF. Everything was going great until the patient called in a panic. She said that her insurance company said that IVF could not be approved because she had not completed all the needed tests. I couldn't imagine what was going on so I called them and got a representative on the phone. Here is our conversation as I remember it:


DrG: Hello, I am calling about Mary Brown (not her real name) and I was wondering why her IVF was not approved.

Insurance agent: Hello, Dr Gordon. Well, she hasn't done all the needed infertility testing yet.


DrG: Really? What is she missing?


Insurance agent: We don't have the results of her post-coital test.


DrG: That's because I didn't do one.


Insurance agent: We can't approve IVF until we know the results.


DrG: I didn't do one because her husband is azoospermic...he has no sperm in his ejaculate.


Insurance agent: Still, I need to know the results of a post coital test.


DrG: Do you understand that the post coital test looks for sperm in the cervix and since he has no sperm the test will be pretty obviously abnormal....


Insurance agent: Still, I need to know the results of a post coital test.


DrG: Hold on a minute....(10 second pause) ...OK I just did the post coital test. It shows no sperm...


Insurance agent: Thanks Dr Gordon she is approved for IVF.


Funny but sad.... OK so here is today's Question of the Day from the upcoming book by yours truly.


20. Will my insurance pay for my fertility treatments?

Insurance coverage for infertility varies widely across the United States. Several states, including Massachusetts, Illinois, and Maryland, have passed legislative mandates for infertility coverage. In these states, access to fertility treatment is guaranteed through the patient’s employer. in the vast majority of states, however, fertility coverage is inconsistent. Some companies may offer extensive fertility benefits, while others offer no coverage at all to their employees. It is important that you understand your specific benefits before you seek out any kind of fertility treatment. Insurance plans may provide a specific dollar amount to spend on fertility treatments or cover a certain number of cycles of either IUI or IVF. You should work with your fertility provider’s billing staff to determine which benefits are available to you before launching into a treatment plan. Given that some insurance plans may cover infertility more extensively than others, it is always appropriate to examine your insurance options during periods of open enrollment for health benefits. Many insurance companies will not cover fertility treatments in patients who have been voluntarily sterilized (e.g., vasectomy, tubal ligation). Plans may also have specific requirements in terms of duration of fertility and exclusion criteria for IVF concerning ovarian reserve testing or age.