BCBS FEP $40 copay no longer $40 with IVF?

[Anonymous]

I have BCBS Federal Employee Plan and up until now have always paid only $40 for monitoring appointments, even during IVF cycles. I've done this at Shady Grove and CFA for a long time.

CFA just sent a claim in from an FET cycle and my insurance has determined I now owe more than the standard $40 copay because some services (standard monitoring bloodwork) were provided in conjunction with services they don't cover (IVF). When I called, BCBS told me that they requested a "medical review" and after receiving my records from the provider, they are deciding not to cover. I'm really nervous about back-review of claims that were already covered now coming back to haunt me. This actually did happen to me with another provider after the BCBS "medical review" and now I owe $$$$.

What's going on here? Why now? Is this a new thing? Does "medical review" happen when you've been a heavy user of the system or are they starting to do this routinely more? Has this happened to anyone else?

[Anonymous]

I’m actually surprised they were covering it at all since it’s IVF. Was it only 40 even for ultrasounds?

[Anonymous]

Anyone has an idea as to how far back the insurance company can go with these potential “back reviews”. If feel like if the insured has 6 months to appeal a decision, the insurance company should be held to a similar standard, though that’s probably not how it works...

[Anonymous]

From googling it appears that there is a 6 month to 18 month limit in DC and Maryland. I've provided the links. Just to clarify, I have no other information and am not sure my understanding is correct.
https://code.dccouncil.us/dc/council/code/sections/31-3133.html
https://law.justia.com/codes/maryland/2010/insurance/title-15/subtitle-10/15-1008/

[Anonymous]

This is OP. I haven't looked at PP's link yet, but insurance told me they can review claims for up to 5 years

[Anonymous]

Anonymous wrote:This is OP. I haven't looked at PP's link yet, but insurance told me they can review claims for up to 5 years

Ugh. That is infuriating. I am so sorry!

[Anonymous]

OP, I would repost your opening thread under a different title (such as “BCBS FEP potentially retroactively denying monitoring coverage” or something like that) in order to get more feedback/reactions. When I first saw the title of your post, I assumed it was merely about the copay going up. The implications are far more important/distressing. Let’s just say that if they retroactively deny your monitoring claims, they will do so for a LOT of other people.

[Anonymous]

I have done multiple rounds of IUI and IVF and have never had insurance coverage for any of it. One thing I have noticed is that the clinics (CFA and Penn medicine in Philadelphia) charge you a package fee for the cycle but then also bill anything they can to insurance bc I received EOMBs for dates of service related to the cycle.

If insurance companies are getting wise to this approach and denying claims that sucks bc it means that clinics will likely increase their prices. However I feel like if you paid a package fee up front for services included in the cycle, its unfair for the clinic to come after you for co-pays bc insurance companies changed their policies. I would look at the language of the paperwork given to you by CFA and see what if anything it says about co-payments or if the price you paid is your maximum out of pocket cost.

[Anonymous]

The thing is: it's not necessarily the clinic coming after you, it could be the insurance company.