Help being my own advocate for billing issues

[Anonymous]

I'm having a billing issue, and I'm wondering if others have advice. I switched insurance this year to get coverage for infertility treatments. I have coverage for both IUI and IVF under my new insurance, and this is likely our last IUI cycle before making the switch. Because of timing, we did the IUI early in the year. My insurance (MDIPA) requires pre-authorization. Prior to my treatment, the insurance company asked for additional information which I was told was sent prior to my procedure. Because the coverage was still pending at the time of my procedure, I was told to wait because coverage could be applied retroactively.

Now, almost two weeks later, I called the insurance company only to find out that they never received the requested information and so were waiting to finish processing my pre-auth. Apparently, there was an error in their fax number (I was able to determine this in less than 10 minutes on the phone). Apparently, my clinic's billing office never bothered to check if the information was received and has instead simply been repeatedly faxing it with no reply.

I'm scheduled for my 2 week blood test tomorrow, and billing is telling me that even though pre-authorization is still pending (at least partially through the clinic's error in my view) I will have to pay the full charge before getting anymore treatment...but they will reimburse me if insurance eventually provides coverage. While the amount is not the issue, I am very hesitant to do so. I also find it appalling that any doctor's office would treat a patient like this. I'm tempted to either go for my blood test and refuse to pay and leave if they insist, or skip it altogether (the wait is agony, but I'll probably know by Monday if the treatment was successful regardless). I also think I may contact my RE directly to let them know what's going on. This is minor compared to getting IVF approval.

Am I over-reacting? I'm fairly familiar with medical billing in other specialities, and I don't think I know of any other doctor's practice that would insist on payment under these circumstances.

[Anonymous]

If you think you can skip the blood test, I think that I might do that and talk to your RE. I wouldn't go back until the billing issue is resolved. I'm not bold enough to leave if they insisted I pay, so I'd rather avoid that kind of confrontation.

[Anonymous]

Let me guess, CFA?

[Anonymous]

Actually op, 2 of my doctors and a couple of doctors I know through friends require payment up front if you don't have prior authorization/referral etc. Blame the people who don't pay their balance or lie about their insurance getting a prior authorization and then never doing it. My friend works for a doctor's office and they have 10s of thousands of money owed to them because of situations like that

[Anonymous]

22:46, I agree that people are often bad about paying bills. In this case, however, my clinic's billing office failed to send the information requested by the insurance company (and pre-authorization could have been granted if they had). If I hadn't been aggressive about following up, they never would have figured out their error and I'd be waiting indefinitely to get approval for my treatments (and losing precious time). As I said, it took me only a few minutes on the phone with my insurance to figure out the error.

Overall, I think I've decided to notify my RE and refuse to pay until they have a resolution from my insurance. My father is a physician in private practice, and he thinks that it is absurd that the billing office is treating me this way. Doctors have to write off bills all the time, and in this case it is the clinic's error!

In general, I'm starting to feel like fertility clinics know that patients are so desperate for treatment that they are willing to pay out of pocket for treatments that should be covered. This lets them get away with billing practices that no other medical provider possibly could.

[Anonymous]

Op, I agree to refuse to pay, skip the test if necessary. Once they have your money, they can really drag their feet, and then you have to go through trying to get a refund from them.

[Anonymous]

Fertility is big business, never forget that. I second the advice above. They know you are desperate and it is a tough situation. i hate that you can't separate the financial issues from the treatment. Wait to have the test. Call them and calmly explain you need to get the approval first. Call your insurance company and be really nice to your case manager. Apologize, ask her or him to help you. Be super nice and deferential to them, annoying but you will be surprised sometimes people really will help you. Good luck! I hate the financial side of this, weighing options, cost, additional stress...so unfair.

[Anonymous]

It is disappointing that the staff at your doctor's office did not confirm that the pre-authorization was received by your insurance company and you will suffer because of it.

Even though the practice's office did not follow through, they may demand payment according to their office policies. More and more practices are implementing this protocol - payment at point of service for deductibles, co-pay, non-covered services, etc. - as health insurance premiums have left many uninsured or underinsured.

When you are discussing what happened with the practice and or billing manager, keep to the facts. If you have a record of who you spoke with and when, this will be in your favor. Sunni Patterson, Co-Founder, medicalinsuranceclaimhelp.com.

[Anonymous]

I used to handle pre-auths for an RE office and MDIPA generally processes theirs within a week or so. That said, full payment up front isn't out of the ordinary, especially considering that insurance will likely reimburse pennies on the dollar once everything is approved. I know this isn't the norm for medical care but this isn't a life or death situation, this is optional treatment.

Just to clarify, you said two week labwork. Is this post IUI HCG testing? If so, why not go to a lab? Or is this like to check LH levels on CD 12/13? I would think a sono to check follicles would be more telling.

Lastly, I would ask the office if they offer a flat fee for the IUI cycle. That would cover labs, sperm wash, sono, insemination, etc.

And here it is 12 days later but I already typed this out on my iPad screen so I'm going to post it anyway. Hope this brings you a BFP.

[Anonymous]

Anonymous wrote:I used to handle pre-auths for an RE office and MDIPA generally processes theirs within a week or so. That said, full payment up front isn't out of the ordinary, especially considering that insurance will likely reimburse pennies on the dollar once everything is approved. I know this isn't the norm for medical care but this isn't a life or death situation, this is optional treatment.

Just to clarify, you said two week labwork. Is this post IUI HCG testing? If so, why not go to a lab? Or is this like to check LH levels on CD 12/13? I would think a sono to check follicles would be more telling.

Lastly, I would ask the office if they offer a flat fee for the IUI cycle. That would cover labs, sperm wash, sono, insemination, etc.

And here it is 12 days later but I already typed this out on my iPad screen so I'm going to post it anyway. Hope this brings you a BFP.

Full payment upfront is great if you can be sure that any money due you (once insurance pays the RE) will be credited back immediately. I've dealt with a local clinic and had to fight for months to get my refund -because they kept messing up the insurance processing. I will never fall for that again.
I realize this is not life-saving treatment, but consumer proctection organizations call this kind of behavior predatory. And, of course, doctors don't want to get involved. They just want their paychecks.

[Anonymous]

Anonymous wrote:

Anonymous wrote:I used to handle pre-auths for an RE office and MDIPA generally processes theirs within a week or so. That said, full payment up front isn't out of the ordinary, especially considering that insurance will likely reimburse pennies on the dollar once everything is approved. I know this isn't the norm for medical care but this isn't a life or death situation, this is optional treatment.

Just to clarify, you said two week labwork. Is this post IUI HCG testing? If so, why not go to a lab? Or is this like to check LH levels on CD 12/13? I would think a sono to check follicles would be more telling.

Lastly, I would ask the office if they offer a flat fee for the IUI cycle. That would cover labs, sperm wash, sono, insemination, etc.

And here it is 12 days later but I already typed this out on my iPad screen so I'm going to post it anyway. Hope this brings you a BFP.

Full payment upfront is great if you can be sure that any money due you (once insurance pays the RE) will be credited back immediately. I've dealt with a local clinic and had to fight for months to get my refund -because they kept messing up the insurance processing. I will never fall for that again.
I realize this is not life-saving treatment, but consumer proctection organizations call this kind of behavior predatory. And, of course, doctors don't want to get involved. They just want their paychecks.

Well....yeah. That's the point. Who should bear the burden of the risk that the insurance company won't pay? You, the person receiving the expensive treatment, or the doctor providing the expensive treatment?

[Anonymous]

I understand here there probably wasn't anything the OP could have done ahead of time, but how do we avoid these problems in the first place? I've also now switched to MDIPA where everything has to be pre-approved. I'm assuming that my drs office is requesting the authorizations, but it's not like they ever call me to tell me that, e.g., my spouse's semen analysis is approved. We just go in on the day of the appointment and assume (probably naively) that everything is being taken care of. Should I be bugging the drs office a few days before every appt to ensure the procedure has been approved?

[Anonymous]

18:55, if the docs can't hire competent billing staff to correctly handle pre-certs, they sure as heck can wait for our payments. If a patient could be assured that within thirty days of overpayment on their account they could get a refund, maybe that would be different. But the docs have no right to hold on to overpayments, yet, they do.

So, no, I don't feel too much sympathy for REs (who already get plenty of money from patients who have to pay out-of-pocket, not to mention what insurance is reimbursing them), if they have to wait a little longer because an idiot on their staff couldn't follow through on a pre-auth.

[Anonymous]

Hey 20:46--

we just switched to MDIPA and you can call them and ask for their approvals department to see if your procedures are approved. We're at SGF, and found that it was a waste of time trying to get the status from their financial coordinator. We started calling MDIPA directly and knew about or approval status faster than waiting for SGF to get back to us.