I've had a few doozies over the years. 2003: three stitches. Yes, I was enrolled in college at the time and a dependent on my parents insurance. No, I am no longer enrolled. Yes, I do think you should cover this since I was enrolled at the time. 2009: skin pathologies. Yes, I had a referral to the derm & derm surgeon. No, I did not bring my biopsy or the larger skin sample to the lab myself, so I did not pick the non-HMO lab. Yes, I do want you to work this out with my doctor, and No, I will not pay the fee until it is resolved.
Most recently, a call to the insurance folks, not our benefits office (thinking, crazy me, they could answer my question), more or less verbatim.
Me: Hi, I'm calling about my reproductive benefits.
Customer Service Lady: OK blah blah
Me: So I understand my plan covers 1 IVF at [specific major medical center].
CS: Yes, it does.
Me: Can you tell me what that entails? I'm specifically interested if I can do monitoring at my home doctor, as he doesn't have privileges at SMMC.
CS: Well, I'm not a health care professional, so I can't tell you all the procedures associated with IVF.
Me: Yes, ma'am, I understand. I want to know what specifically needs to be done at SMMC. For example, do I need to do only the egg retrieval and transfer there for coverage, or do I need to have all the monitoring and other visits there too.
CS: Your plan covers one In-Vitrooooo Fertilizzation [very slowly, in case I didn't know what IVF was]. So I think that needs to be done there but you can do other OB related visits elsewhere.
Me: So you can't tell me what exactly needs to be done at SMMC? [I omitted the part about this having nothing to do with my OB, since I realized at this point this was useless]
CS: I can only tell you what I have on your benefits coverage.
Me: Right, I have that list too. So if my doctor's office calls and asks about billing codes, can they find out what exactly is covered and what I need to do at SMMC to get the coverage?
CS: Yes
Me: But all you can tell me is I have coverage for one IVF, but you don't know what procedures.
CS: Right
Me: OK, thanks, I'm going to go beat my head against the side of this train car now.
Its such a nightmare trying to figure out what will/will not be covered. I've gotten different answers every time I've called. Your best bet is to have your RE call with the diagnosis and procedure codes...and even better to request the answer in writing (though that would probably take roughly 5 years to obtain).
ReplyDeleteBest of luck - I completely sympathize!
I know someone who works for Aetna (I think it's Aetna), and her job is specifically related to reproductive coverage issues. I wonder if you could ask for her equivalent at your HMO (if they have someone like that).
ReplyDeleteI'm definitely going to have the insurance girl (I wish I knew her actual title!) look into it for us. I'm not even sure if we're going to do it, but really would like the answers to make an informed decisions. I'm sure there IS someone at BCBS who can answer this question, but I am not entirely motivated to find her (as I'm hoping the doctor's office has a direct line!).
ReplyDeleteUnfortunately I don't know the Aetna woman's title, only that she works in the Fertility Dept. Maybe asking for that will help?
ReplyDeleteThose insurance people can't possibly be medically trained AT ALL. I have talked with them at work before and they know nothing, don't have the slightest clue. I had one lady tell me the plan wouldn't cover a patient's diabetes testing supplies b/c he wasn't on insulin. She thought that everyone who was a diabetic was also on insulin. Um, no.
ReplyDelete