RE and Insurance Coverage – Advice Needed (Long-ish)

Im seeing Dr. B so anyone that has specific info regarding his office specifically I would be really grateful for – but anyone that has any opinion or expertise in the areas of insurance coverage will be GREATLY appreciated.

So my plan (CIGNA) does not have ANY infertility coverage. Nada. So I pay out of pocket for Dr. B appointments which are mainly sonos. The insurance does cover the bloodwork.
I called today to appeal this, I was going to say they should cover the appointments because it is treatment for PCOS which should be covered as an underlying medical condition causing a host of other symptoms which are covered (specifically acne and dermatological treatments for that).
The woman on the phone said that if the office submits the claims under a different code (ie. As the code for treatment of PCOS and not the code for infertility), then they will reprocess and possibly cover the appointments.

So I have a Dr. B appointment this afternoon. When I am in the office I want to request that they resubmit some of the claims as treatment for PCOS so that they are covered. I am nervous about this and feel weird about asking. I mean I am sure that they have had this a lot of times before, but I still feel awkward trying to go around the system even though its all true. I mean I would never ask them to submit like an IUI or anything that truly falls under infertility and nothing more. But the truth is I HAD to go to Dr. B to even get a real diagnoses and subsequent treatment. My whole life I had acne (except when I was on BCP for 12 years) and I never knew the underlying cause. It seems foolish that the insurance company will cover me for the symptom and treatment of the symptom, but not the underlying cause of the symptom (high LH = elevated testosterone, PCOS).

SO all of that being said – is it OK for me to go to Dr. B’s office and request that they submit the claims that way so I can get covered?? I know Dr. B himself would be fine with it – since he has done everything in his power thus far to help on the financial front. He’s really amazing like that. I just feel weird about asking the nurses and stuff.. What do you all think? Do you think I have any shot of getting any of this covered?

TIA!

Message edited 11/27/2009 10:40:55 AM.

Re: RE and Insurance Coverage – Advice Needed (Long-ish)

I think it's fine and I've done this before with other doctor offices.

It's worth a try and I would definitely keep your appt.

Re: RE and Insurance Coverage – Advice Needed (Long-ish)

I think any office would work with you. I do not go to Dr. B., but from the posts I have seen about him I would definitely mention it to HIM, not just his office staff. He seems to have a heart of gold and would ask his office staff to bill it under the code that you need. It never hurts to ask, especially if it could relieve the financial burden for you.

Good luck!!!!!

Re: RE and Insurance Coverage – Advice Needed (Long-ish)

thanks for the replies!!
so i just need to ask if they can bill it differently?
i will DEF say it to Dr. B also, since yes he does have a GIANT heart of gold.

i just hope that its not awkward. ive never had to do this before..

Re: RE and Insurance Coverage – Advice Needed (Long-ish)

Just make sure to tell him what the lady from insurance said. Basically if you have already paid out of pocket, the check will come to you to reimburse you. So in the long run Dr. B. has nothing to loose.

Re: RE and Insurance Coverage – Advice Needed (Long-ish)

I understand it might be awkward but I would try it... and I would really try to come off like "I am so happy to be dealing with your office.... its just a huge financial straing..." I find when I make myself vulnerable I get more help.

Good Luck!

Re: RE and Insurance Coverage – Advice Needed (Long-ish)

It is totally not a big deal. Just tell him it might be covered under PCOS and not infertility. It won't make a difference to them at all.

Re: RE and Insurance Coverage – Advice Needed (Long-ish)

thanks everyone!
i told the nurse and she said she would put it in the computer and see what happens. it wasnt awkward.
i will tell dr. b too next but he wasnt there today so i just met with the nurse.

looks like i have a "promising" follie...14.4...
it matures.

Re: RE and Insurance Coverage – Advice Needed (Long-ish)

Yay! I am glad it worked out- as least they will bill it that way so you will never have to wonder.

Re: RE and Insurance Coverage – Advice Needed (Long-ish)

The doctor is going to get paid either way, from you or your insurance, so it should make no difference to them how they bill it.

Glad it went well and

Re: RE and Insurance Coverage – Advice Needed (Long-ish)

Another money saving idea is to put money into your flexible spending account (FSA) at work. Things like IVF medication and costs, prenatal vitamins, cold medicine, contact lens solution... are all available to buy tax-free. This can add up to a lot of savings.