At Reproductive Medicine and Surgery Center of Virginia, PLC, we want you to understand both the medical aspects of your care and the cost of your fertility treatments. Our staff has many years of experience in the fertility insurance arena working to maximize benefits to help offset infertility treatment costs. Our insurance advisers are here to answer any questions you may have.
Unfortunately, infertility treatment coverage is not easy to obtain and is not common in Virginia. Most commonly infertility coverage does include diagnostic testing (testing to determine why you are infertile), but not the infertility treatment to help you become pregnant. Some medications may or may not be covered. Sometimes the insurance representatives do not give an accurate assessment of your fertility cost benefits. We will help you to understand what fertility benefits you have and make the process easier.
Services We Perform for You as a Patient
We request that you fax your insurance card to our office prior to your appointment so that we may obtain your benefits. We will normally contact you prior to your initial visit to review the information that we obtained from your insurance company and you will be more informed about infertility treatment coverage for your first visit. At your initial visit, we will provide you with a copy of the benefits that we received, as well as a price sheet. If at any time you feel you have different infertility coverage, or a different level of benefits, please notify us and we can clarify the details. We also recommend that our fertility patients call their insurance company and speak directly with the representative.
Obtaining these benefits does not guarantee payment of services and insurance companies often will give a generic disclaimer. A common disclaimer would be “coverage is not determined until the claim is processed.” Coverage is based on several factors: if the service and reason (diagnosis) is covered by your plan; deductibles and co pays have been met; and whether a pre-existing condition applies or not. In some cases, more complicated requirements for insurance coverage for services rendered include: you must be infertile for a specific length of time before coverage begins or the cause is not due to a previous tubal ligation. Some companies go as far as deciding which medical tests or treatments must be completed before coverage begins, which may not be the treatment plan our physician recommends for you.
Obtaining authorization or a referral (for managed care policies) for your initial visit is your responsibility. We are happy to assist you with this if needed. You also must ensure that you keep your referral up to date as insurance companies will not retro referrals. We will obtain follow up authorizations as your insurance company instructs us. Please be sure to always check out with one of the receptionist to touch base regarding insurance needs as well as paying co pays and other balances as required. This will help cut down on the number of denial letters and higher patient costs.
Claims Filing
We will file all claims for you if we participate with your insurance company and if they inform us you may have coverage for services rendered. We will collect all co pays for office visits and co-insurances for surgery up front as well as the full amount if you have no fertility coverage under your policy. You will be billed for any balances your insurance company does not cover (and once we have exhausted all avenues for obtaining payment). The outpatient coinsurance’s that we collect are estimates only and based on actual charges to your insurance company as well as payments received from your insurance company.
If we do not participate with your insurance company, we expect payment in full at the time of your appointment. As a patient, we will provide you with the necessary information regarding services provided in order for you to file a claim directly to the insurance company for reimbursement. You must obtain the claim form from your insurance company.
If you will be undergoing in vitro fertilization, there are payment options that are not addressed in this letter. If IVF is your next treatment plan, you will talk with a financial representative at the practice regarding your choices.
You cannot be billed for services rendered if we do not participate with your insurance company or you have exclusions on your plan. Also, any balances on your account will be due at the time of your next visit.
There may be times when you have become a self pay or non-insurance coverage patient, but you come into the office with another non fertility related complaint (i.e., pelvic pain, bleeding, etc) or your diagnosis has changed for other reasons (a cyst found on ultrasound during a treatment cycle). If this is the case, we will bill your insurance plan for these services. However, if you come back to resume fertility therapy and your diagnosis has reverted back to infertility; the front desk will no longer bill the insurance company.
Currently we participate with: Aetna Chickering, Anthem, Blue Cross and Blue Shield, Cigna, Community Health/Optima, First Health, Mamsi/MDIPA, Optimum Choice, Sentara, Southern Health, United Healthcare, Tricare and VHN (subject to change without notification).
It is important that you understand our physicians offer their medical recommendations and treatments based on your history, physical exam, and test results and not what your insurance company will/will not cover. However, if you have restraints within your insurance coverage that you are trying to meet, please inform your physician so that together you and he can make the best and most cost-effective plan of treatment for you.
Medications
Due to the complexity of our type of medical benefits, we do not obtain the details of coverage for fertility medications. Often times these medications are not covered under your medical benefit, but under your prescription benefit and we do not obtain that insurance card. There are many stipulations for these type of prescriptions such as requiring that you receive them from a mail order specialty pharmacy (often times they can not get it to you in a timely manner) or only being covered prior to any type of artificial insemination. There may be no coverage at all.
Medication benefits and authorizations are the patient’s responsibility and we will help out by supplying whatever information is requested of us. Please keep in mind that if a covered benefit, you need to find out if it is covered under your medical insurance or prescription insurance, where you can obtain the medications, and to get authorization (if required) ahead of time.
Patient Balances
Here at RMSCVA we have a $1500 patient balance limit. You will be allowed to complete your current cycle if your account reaches this maximum, however you will be contacted by the practice and a new treatment cycle will not begin until your balance is paid in full.
Again, what the insurance company tells us is never a guaranty of payment and so if services are denied even after being told they would be covered, and we have researched the denial and are in agreement, you will be responsible for payment. We will pursue every reasonable option to collect from your insurance company. Payment and any balances are due at each visit.
We understand that your situation is a stressful one and insurance companies in this specialty do not make it any easier. We want to do our best to keep you informed of your insurance benefits and balances within the practice. Please feel free to contact us at anytime with financial or insurance questions.
Sincerely,
Jody L. Halloran
Practice Administrator
Reproductive Medicine and Surgery Center of Virginia, PLC
