SG - question if you are out-of-pocket, dealing with insurance, flexible spending, etc.

[Anonymous]

I'm doing IUI at SG and my insurance doesn't cover it. So, I am technically out of pocket. However, I have a separate insurance plan that is not health insurance but provides reimbursement for certain out-of-pocket medical expenses (it's NOT a flexible spending acct, which I also have, but it's similar in some ways). Under this secondary plan, I must submit an explanation of benefits from my primary insurance, showing the charges I was responsible for, and then they reimburse me. They don't accept credit card receipts, etc. - they requires something from the primary insurance showing how much they paid.

My problem now is that SG will not submit anything to my primary insurance related to the IUI cycles. They submitted for my diagnostic stuff but told me that they are not even allowed to submit for IUI b/c it's not covered. On the other hand, the insurance company just told me SG is required to submit it or I'm not responsible for the charges!

The cryptic, somewhat incomprehensible account statements I have been able to wheedle out of SG do not contain enough information for my primary carrier to process the claims. The primary is insisting on diagnosis & procedure codes, etc., and SG is insisting that they cannot provide anything like that since the cycles are global fees, not itemized services that are coded individually. So all I can get from the primary carrier are denials that say the claim can't be processed without more info and/or that the charges weren't submitted properly by SG and therefore no one is responsible (not me or the insurance co.).

I just spent an hour on the phone with my primary carrier explaining that I don't want them to pay for this, I just want a denial showing that I'm responsible for the charges. They don't think they'll be able to do that.

The whole thing is maddening because I HAVE insurance, yet I'm paying out of pocket because I can't get the right pieces of paper. I have talked a couple of times to my financial coordinator and to someone in billing in Rockville and am not getting much help. They just say all they have is the account statement printout, nothing else.

Has anyone else had to submit things directly to an insurance company? I have never had this problem before but I've also never had a "global fee" service before; usually the thing from the Dr's office has a dx code and procedure code. What piece of paper do you submit to your insurance? And if you are out of pocket, what do you submit to your flexible spending account??

[Anonymous]

Does the insurance company have a claim form that you can fill out and submit directly to the insurance? If they do, fill out the form and send it in. They will send you back an EOB showing the charges are not covered. Then you can send that on to your flex-spending type account.

I am surprised that SG doesn't have some type of service breakdown. Can you call back and ask for a list of what is included in that global fee, at least? They might not be able to say ultrasounds costing x dollars, but they should be able to say a more generic "global fee includes: ultrasounds, bloodwork, retrieval, anesthesia, etc."

[Anonymous]

P.S. I did IVF at Columbia Fertility. For my flex spending, I submitted a letter CFA provided stating the procedure and what it cost/included. I also sent a photocopy from my insurance plan's benefits book stating that IVF was not covered. I had no problem getting this processed, and I did not get an EOB for this particular instance.

[Anonymous]

Does the insurance company have a claim form that you can fill out and submit directly to the insurance? If they do, fill out the form and send it in. They will send you back an EOB showing the charges are not covered. Then you can send that on to your flex-spending type account.

Yes, I did send in the claim form along with my "receipt"/account statement from SG. It was rejected b/c they need more detailed info, which SG won't provide. They also won't provide anything general like "global fee includes ___" - which won't help me anyway as my insurance is insisting on the codes for all services. Again, I can get a denial that says "we can't process your claim" but what I need is a denial that says "it's not covered and patient is responsible for $XX." Doesn't sound so hard, right? Turns out it's impossible!

But, I will keep working on it. To the Columbia PP, the idea of submitting a page from my plan is helpful; I'll try that too, thanks. And I'll see if I can get SG to produce something (a letter, something) that my secondary plan might accept.

One issue is that my secondary plan is technically an insurance plan, so there is an annual premium, and they will reimburse up to $XX of qualified medical expenses per year. (Before you ask me why I signed up for this thing, I didn't. It is through Dh's work, and participation is mandatory; he has the premium withheld from his pay & we cannot opt out. So we are paying the hefty premium even if we don't submit any expenses for reimbursement -- another reason I am really burned up about not being able to get reimbursed!) With flexible spending, it's your money in the first place, so it seems a little easier to get it back & they're less rigid about documentation. But I'm trying to get payment from an insurance company, which, as we all know, is a different thing altogether.

[Anonymous]

I am out of pocket for all procedures at SG and pay a global fee for IVF. My expenses are great enough that I can write a portion off on my taxes and require detailed documentation to support my claim which should be the same as you have requested. I have been able to get a printout (not the green and white bills, but more of a report) when my cycle is 100% complete and posted in their system, usually a couple of weeks after my beta is drawn, that has the diagnosis and procedure codes. I am actually looking at a printout right now and it definitely has that information. Granted, the individual monitoring visits on a global fee IVF are not itemized, but the retrieval, transfer and assisted hatching are all detailed. And, for the one IUI conversion I had it lists it as aritificial insemination. Have you actually completed your cycle yet or are you looking to get the funds upfront to cover your cycle?

[Anonymous]

I am out of pocket for all procedures at SG and pay a global fee for IVF. My expenses are great enough that I can write a portion off on my taxes and require detailed documentation to support my claim which should be the same as you have requested. I have been able to get a printout (not the green and white bills, but more of a report) when my cycle is 100% complete and posted in their system, usually a couple of weeks after my beta is drawn, that has the diagnosis and procedure codes. I am actually looking at a printout right now and it definitely has that information. Granted, the individual monitoring visits on a global fee IVF are not itemized, but the retrieval, transfer and assisted hatching are all detailed. And, for the one IUI conversion I had it lists it as aritificial insemination. Have you actually completed your cycle yet or are you looking to get the funds upfront to cover your cycle?

I think I have the printout you're referring to & it's not satisfying my insurance co. It's not in front of me now, but it just lists one charge/service per cycle. For diagnostics, it details each date of service, but not for the IUI cycles. Maybe it's more detailed for IVF? I'm on my 3rd cycle - 1st cancelled so did not make it to insemination; 2nd failed; still waiting to find out about 3rd. So no, I'm not seeking payment up-front, I'm just seeking reimbursement for what we've already shelled out. (Actually only the 1st 2 cycles; I haven't asked SG for anything for the 3rd cycle yet.)

Anyway, I'm going to keep trying if I can figure out what else to do. I wish there was some way I could conference call SG and my insurance; I may try that next. It's really frustrating to be getting completely opposite answers out of them & I'd like to hear them hash it out on the phone. I'm not asking for my primary insurance to cover something that's not covered under my plan, and I'm not asking SG to provide anything extraordinary, just an understandable and complete bill.

I don't think I should be paying out of pocket for something that I have reimbursement insurance for, just because no one can print out an appropriate piece of paper that says what the other guys want it to say. It is literally to the point where if this current cycle fails, I will not be able to do a 3rd IUI cycle because we did not plan to be paying out of pocket for this and do not have the funds. I have primary insurance coverage for IVF and would have gone straight to that if I knew I was going to get stuck with this bill.

[Anonymous]

Have you talked to the billing person in the Rockville office who works with your insurance company or just the financial coordinator in the office where you get treatment? I only ask because the billing person may have more insight and may be able to help you out. Another suggestion is to talk to one of the financial coordinators in another office to see if they have any suggestions or ideas.

[Anonymous]

Have you talked to the billing person in the Rockville office who works with your insurance company or just the financial coordinator in the office where you get treatment? I only ask because the billing person may have more insight and may be able to help you out.

Unfortunately, yes, I've also talked with the billing person in Rockville. I've explained the situation ad nauseum but it seems they can only print out what they can print out, they won't create a document for me or provide anything directly to the insurance company. So if that computer printout of the account statement doesn't cut it with my insurance, there doesn't seem to be much else I can do.

Today I wrote a letter to the secondary insurance explaining which charges weren't covered and that my primary won't give me an EOB, and I enclosed the SG account statement showing the charges. Normally they won't accept anything other than an EOB from the primary, but maybe I'll get lucky . . . .

[Anonymous]

What do they mean they aren't allowed to submit to your primary insurance because it isn't covered? That sounds like a cop-out to me and I would threaten to report them to the insurance commisoner (and actually go through it!). I know you have already gone through it with them, but tell them you want it to go through your insurance company or for them to provide you with the inforamtion so you can submit the paperwork yourself. They can't deny you the opportunity to submit on your own. Ask your primary insurance company what the process is to submit a claim on your own. Ask if they can call Shady Grove to get the info they need (you never know...you might get someone sympathetic to your cause). I would not let them off the hook. Alternatively, and I may have missed this, can they submit the paerwork to carrier #2? Can you tell them it needs to be submitted so you get credited towards your out of pocket limits?

[Anonymous]

"Unfortunately, yes, I've also talked with the billing person in Rockville. I've explained the situation ad nauseum but it seems they can only print out what they can print out, they won't create a document for me or provide anything directly to the insurance company."

Did you talk to the person in Rockville who is in charge of your insurance plan (the one that would be rejected)? I had a similar issue in that my insurance company insisted I had coverage for meds (they were wrong, but that is what they said) and SG insisted that I didn't, and the pharmacy wouldn't fill my script because they were waiting for SG to submit something to the insurance company, which my billing person wouldn't do. I finally talked to the women in Rockville who was in charge of BCBS and explained the situation to her, and even though she told me that it was a worthless exercise she went ahead and submitted the claim for me.

If no one in Rockville will help, then I would complain to your doctor. You shouldn't have to get him/her involved, but if you are getting screwed financially then they'll just have to deal if they want your business.

[Anonymous]

Did you talk to the person in Rockville who is in charge of your insurance plan (the one that would be rejected)? I had a similar issue in that my insurance company insisted I had coverage for meds (they were wrong, but that is what they said) and SG insisted that I didn't, and the pharmacy wouldn't fill my script because they were waiting for SG to submit something to the insurance company, which my billing person wouldn't do. I finally talked to the women in Rockville who was in charge of BCBS and explained the situation to her, and even though she told me that it was a worthless exercise she went ahead and submitted the claim for me.

I just did this and I think I'm getting somewhere!! Thank you! After going through the whole "we don't submit claims for global fee cycles, if there's no insurance benefit, we cannot submit, blah, blah, blah," I just said "look, I already paid for these cycles. SG has been paid. I know I am responsible for the charges. I'm not asking for a refund and I'm not trying to make my primary insurance pay for this. Would you please just do me the favor of submitting the claims so I can see get a denial? I know you don't normally do it, but most people don't have this weird medical reimbursement insurance that I have." And they agreed to do it and will send them out today with copies to me!

My financial coordinator previously told me on several occasions that SG is "not allowed" to submit these claims and that if they submitted them and they were denied, then SG would not even be able to charge me for them and would not be paid at all. Obviously that's just flat-out wrong.

So, SG is now going to submit claims for all three cycles. Unfortunately I'm screwed for the first cycle b/c it's been more than 90 days, and my insurance has already rejected what I submitted (meaning the EOB says I'm not responsible for the charges either). But for cycles #2 and #3, we are still within the 90-day time frame. And for next cycle (I have a feeling this current one didn't work and I'll be on to #4 next week), they said to call Rockville about a week after I start, once it posts to my account, and they will file an insurance claim for me.

I wish I had been more persistent a few months ago about this, but I took SG at their word when they told me multiple times that there was no way they could file these claims. If I had kept insisting, maybe I wouldn't be in this situation. But hopefully we are on the way to resolving it.

Thanks for the support!