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

[Anonymous]

Actually I just read in SG procedures that they only bill the insurance company for procedures they cover. So if they don't plan on processing something with an insurance company would they even assign it a cpt code? Sorry I am clueless. And is there anything stopping us as insureds from seeking reimbursement on our own from BCBS?

[Anonymous]

Since SG refuses to give you an itemized bill with codes, you can't submit it on your own. That's the trick.

[Anonymous]

What can we do about this? Something here smells fishy.

[Anonymous]

What about asking SG the codes that they WOULD bill, in a "I'm considering treatment with you and want to know what my insurance coverage would be." Would they share that?

[Anonymous]

As far as I know the insurance companies dictate the billing codes, not the clinic. I would call SG and say that I want to know what codes they use when they bill blood work and ultrasounds for patients that have insurance coverage for IUIs through BCBS. If you really want a cover, say you are investigating a new policy for annual enrollment, which is going on right now for a lot of companies and you want to get an idea of what things will cost. But in my opinion you should not need this.

I have been going through fertility treatments for five years, with four different insurance policies and never had an issue getting codes for things. I can also say that clinics make more money off of self pay than they do with negotiated rates with insurance companies for the most part.

[Anonymous]

Does anyone else think sg's policy on requiring day 3 payment of the global fee is a little odd? I was told that I had to make the payment that day to get the "deal.". It just reminded me of an infomercial -"$9.95 if you buy within the next 30 minutes...."

I really like the doctors and nurses there, but am really put off by the financial matters. And I really don't like that my bcbs coverage is billed differently at sg vs. Other clinics. Something's definitely not right with that, but I can't tell whether sg is billing it "correctly," while other places are working around the coding system, or if sg is in the wrong.

[Anonymous]

I think it is standard for clinics to collect the cycle fee upfront on cd3 if you are paying out of pocket, so SG is not doing anything different from other clinics. And, not that different from any other doc I go to for other issues, as they always collect a co-pay or payment for treatment at the time of service. Honestly, how many people would pay for a failed cycle after the fact? It's a business decision and I get it.

Many insurance policies cover monitoring for "diagnostics" only. I know that's what mine did and most other policies cover if you don't have actual IVF or IUI coverage. If that is what your plan covers, then SG is technically correct in not submitting the monitoring for coverage and billing you separately for the actual IVF or IUI procedure.

One more thing to note - SG does have a contract with Aetna that allows you to pay the insurance contracted rate for an IVF cycle - even if you don't have IVF coverage. So, you can get insurance rates even when paying out of pocket. And, you still have to pay for your cycle before starting stims.

[Anonymous]

This is the OP. I finally got around to calling and asking what the billing codes for IUI monitoring/bloodwork would be if I had BCBS coverage (which was a great idea-- thanks, PP). The woman who answered the phone in the billing office was extremely curious about just why I needed to know this and wouldn't talk to me without my giving her an account number so she could see what I had been billed, and if that was correct (I tried to imply I wasn't a patient at first, but when she asked me outright I wasn't going to lie). It was one of those round-about conversations and when I asked to speak to someone who would tell me the codes, she said they would call me back... weird.

[Anonymous]

I was a patient at SG and switched to Cornell. I think how things get billed to insurance are dependent on each clinic. SG bills ER and ET as two items and monitoring is included in those events. At Cornell, my doctor did not take insurance, so I got super bills for everything. Since I had no coverage left, it didn't really matter and my doc there was not in-network either. But, I did notice that Cornell sent me a super bill for every single office visit for monitoring. My DH's semen collection was even on its own bill! So, I really do think it is a matter of how the clinics set everything up and bill for it.

[Anonymous]

This is the OP again-- thanks. I just found it super sketchy to be told that they couldn't tell me billing codes for general BSBC coverage of IUIs (which is what I asked for) without 1) my being a patient 2) knowing my account number. I spoke to a couple people, including a manager, who told me they had no way of knowing who I was and why I was asking these questions... since "anyone" could just call in, they couldn't give me this information.

To me, if the codes are the same for everyone within the same insurance, this seemed strange.

[Anonymous]

This is a PP. I agree.

[Anonymous]

I definitely think SG has set up their billing to maximize their profits, by forcing those with BC/BS coverage to pay the self-pay rate when they add IUI or IVF. I know of people who have gotten them to provide detailed bills, but SG doesn't like to do this because 1) it's more work for them and 2) they make less money. I think this is VERY sketchy.

Someone who has done a cycle of timed intercourse should be able to provide those codes. Anyone willing to do that?

[Anonymous]

Maybe somebody will have the codes. I do want to point out that if your insurance covers diagnostics, then it is appropriate for SG to cover the monitoring for a TI cycle - as it is diagnostic and requires one visit. If the monitoring is being used for IUI or IVF and your insurance doesn't cover monitoring for that procedure, then SG is technically correct in not billing it separately. I think more policies cover monitoring for diagnostics only than they do for general coverage, so SG has simplified their process to cover the majority of patients. Not saying it's right, but it definitely makes it easier for them to manage all of the billing. And, Cornell just doesn't deal with it at all by not accepting insurance and that's a completely different story. With diagnostics only coverage and out of network benefits, I am almost certain that all of my monitoring at Cornell wouldn't have been covered.

[Anonymous]

This totally makes sense (& thanks for the explanation), but at the same time it would be strange to me if SG said they took my insurance but actually didn't...

[Anonymous]

Sure, they do take your insurance. Many employers don't provide coverage for anything infertility related - zip, zilch, nada for any testing, consults, monitoring, etc. A step up from that is coverage for diagnostics - RE consults, day 3 b/w and u/s, HSG, saline sono, pregnancy tests, OB u/s (if you do get pregnant), b/w and u/s for timed intercourse, etc. An HSG and saline sono can run you $1k+ apiece if you had to pay for it out of your pocket. RE consult is ~$300 out of pocket, day 3 monitoring is ~$500. Very few people are fortunate enough to have full coverage that includes coverage for IUIs or an IVF cycle. It's an unfortuante reality of infertility coverage.

And, just so you know, I had one IVF cycle covered by my insurance and it has been diagnostics only since then. While I wish I had more coverage, I feel blessed to have the diagnostics covered, as I would have had to stop cycling a long time ago if I were paying for some of this stuff out of pocket. I have needed needed several HSGs and saline sonos for m/cs, OB u/s for pregnancy, numerous pregnancy tests for whacky betas, numerous RE consults, many cycles of timed intercourse when not doing IVF, etc.