SG and BCBS (Basic)- Did they pay anything?

[Anonymous]

I just asked a similar question on another thread but since I'm taking things in a different direction:

I have BCBS (basic) federal plan. I paid the full 9,500 for IVF at SG but originally suspected insurance might pay for monitoring and bloodwork (since the benefit brochure says anything "diagnostic") but 1) SG told me no, it's considered part of the procedure and 2) the people answering the phone at my insurance company will say nothing besides quoting the brochure (which is unclear to them and me).

Given what I've been reading lately on this board, I'm really wondering if my insurance would have paid for bloodwork and monitoring. Is the only way to get a real answer to submit bills to insurance? And if so, how so I get these for just the bloodwork and monitoring (since I already paid my full cycle)? Or does SG just jack up the costs of the actual IVF procedures if I dont get the "full package" to so it doesnt matter to my own costs if insurance pays for other stuff?

Anyone else been through this? I have to say I don't trust the SG finance people to help me out...

[Anonymous]

SG told us (and I confirmed with Blue Cross) that monitoring and BW are covered BEFORE you start a treatment cycle (day 3 dor example). Once the treatment cycle is initiated (the day you start meds), nothing is covered anymore because it is considered "treatment." So I don't think they would have paid for bloodwork or monitoring for your cycle. We did IUI and paid the gloabl fee. Once we got pregnant, SG started submitting claim to Blue Cross for the two ultrasounds they did and those were covered b/c they were considered OB care. That was our experience but I agree, nothing seems to be clear with this.

[Anonymous]

SG just told me what 17:50 said.

[Anonymous]

Thanks so much. SG told me the same as both of you, but admittedly I don't entirely trust their financial procses and appreciate the confirmation.

If anyone has successfully had monitoring covered during a cycle, however, please let us know!

[Anonymous]

At CFA, I had my monitoring covered during two different IUI cycles. This was in 09. Originally, they had told me the same thing as SG is telling you, so I was just doing timed intercourse cycles. Then they told me the policy had changed, so I went for the IUIs. I really do think this is worth pushing, because I've heard of other people who have had it covered, even at SG. I think they got BC/BS involved to advocate for them?

[Anonymous]

Pp, not the OP, but do you have any recommendations on how to go about pushing the issue with sg? I've hit a brick wall at my office (not Rockville) and with bc/bs. Does Rockville have ultimate authority over financial matters at sg? Thanks in advance.

[Anonymous]

I am the one who spoke to SG yesterday and I was very frank with Macy -- who is one of their two financial people -- that I had heard that some people were able to get BCBS cover their monitoring and blood work during an IUI. She said no because it's billed as a treatment. I said is there no way around that, no way to bill it differently so that it is covered. She said, no because BCBS's policy is only to cover those as diagnostic testing not once a cycle starts. And I said, huh, then I wonder how these people are getting it covered, there must be some way. She again responded, not if the monitoring is part of the IUI process. So I let it go at that point. Do you really think it's how they choose to bill it so they get more $$? Or do you think perhaps it's viewed as trying to get around BCBS's policies if you bill it as anything other than part of the treatment?

[Anonymous]

This is the OP. Thanks for all the responses. I actually pesronally haven't heard of any one successfully getting monitoring (bw, U/S) paid for during a cycle... so part of me wonders what, if anything, you can realy do.

I HAVE however heard of SG being really shady about some of their financial practices. So, when I put the two together, I really start wondering (and I especially wonder because it seems like the insurance company -- while not dodgy -- is not the most forthcoming with information, either)... but that doesn't mean at all that they would pay for US and bloodwork during the cycle.


I also wonder if SG would hike up their costs IF your US and BW were covered by insurance... i.e., you would no longer be eligible for the universal (9,500 for the first try) fee. In other words, you'd still be paying the same amount. I HAVE heard they do similar stuff with payments- charge the insurance companies less than they do individuals (which is frustrating but from a busienss perspective understandable).

[Anonymous]

Get the codes! Ask specifically what code they would use to bill the blood work and ultrasound and then call BCBS and see what their coverage is for that code.

I used to have BCBS (the higher option) and they paid for my monitoring. I am with CFA.

[Anonymous]

I think that is the issue -- they don't code the monitoring separately - they code it all as one treatment -- IUI or IVF. Or that is what I was told.

[Anonymous]

They don't code monitoring separately for IUI and IVF cycles. They will bill your insurance one amount for retrieval and another for transfer. The monitoring is baked into those amounts. And, no, I don't think they would jack up the costs if your monitoring were covered in an IVF cycle.

[Anonymous]

Great idea, 13:27. So is it possible to get SG to give codes for monitoring and bloodwork that's NOT universal? It sounds like it's their policy to give one universal code. Is that allowed?

[Anonymous]

Okay, that just sounds wrong to me. There has to be a code. If they have someone that has insurance coverage, and some BCBS policies do have coverage, then there is a code that they use for monitoring. When they bill insurance companies they do not bill them one lump sum, they bill for procedures. There is a code for ultrasound, there is a code for each kind of blood work etc. They should be able to give you this code and then you can call BCBS and give them the code. They can pull it up on their computer and tell you if it is covered under your policy. The issue you may run into is if the blood work was not sent to a participating lab.

Reading this makes me glad I am not a SG patient.

[Anonymous]

I actually do think this is all about which way SG makes more money. They claim they're cutting you a break on individual costs by charging one grand fee for self-pay IUI or IVF patients. And that may be true in some cases (when you have a lot of ultrasounds or a lot of eggs). But in many cases, they make more than they would if they charged for each service. I think this is unethical and perhaps illegal. I do know I've talked to people who have been able to get their bloodwork and ultrasounds covered at SG (and I did at CFA). Not sure how they did it. Probably kept pushing it with someone in Rockville's finance office and got BC/BS on the phone as well.

[Anonymous]

This is the OP. I think I might try calling BCBS and saying that I have a potential problem with the way SG is handling things and explain my situation.

The problem is that when I call BCBS, they really do only read the unclear information that is posted in the brochure (from the run-around I've received from them, I assume their customer service representatives are instructed not to interpret-- which given that they likely don't have IF experience, I'm not sure they are qualified to do anyway). So how do I get someone at the insurance company to help me with this?