Insurance. I bet half of you just tensed up, and the other half’s eyes have already started glazing over. Hang in there, this is important! If you can get past your initial apprehension about having to deal with the often bureaucratic nightmare that is insurance coverage, you are in a position to really help yourself financially (and stick it to the big, bad insurance company!)
After you meet with your doctor and have your infertility diagnosis and treatment plan, the next challenge you may face is the cost of your treatment. Insurance coverage for infertility treatments varies depending on where you live and what insurance plan you have. No matter what your situation is, you need to advocate in order to make the most of your insurance coverage and mitigate the cost as much as possible.
Dealing with the complications and red tape a health insurance policy or company presents can be frustrating and time-consuming. You want to make sure you avoid unexpected bills you thought were covered, and you may also find yourself having to appeal a claim denial. People making infertility claims commonly receive notification that they will be denied coverage for treatment because insurance companies know that a large percentage of their customers who are denied will never file an appeal. However, appealing a denied insurance claim is an important step to take because it will not only help you, but it could provide benefits to others in the future as well. Companies may eventually change their guidelines and denial practices if they are challenged.
For someone who is already dealing with the physical and emotional challenges of infertility, dealing with the administrative and bureaucratic hurdles of insurance is likely one of the last things you want to do. However, by using these resources to educate yourself and to practice self advocacy, you will ultimately succeed in your journey to empowerment.
Practicing strong self advocacy will greatly improve your chances for success in getting the coverage you need. Fertility Within Reach provides the following tip sheet to help prepare you for communicating with your insurance company and guide you through the advocacy process with your insurer. Be sure to visit their site for more tips and specific instructions on how to deal with the appeals process in particular.
CHECKLIST FOR COMMUNICATING WITH YOUR INSURANCE PROVIDER
Organization and evidence are critical to confidently communicate with your insurance company. Please use the checklist below to prepare you to advocate with your insurance company.
UNDERSTAND YOUR COVERAGE
- Know the basics. Insurance can be complicated. Prior to visiting your physician it is important to have a basic understanding of your coverage. Upon request your employer or insurance company should provide you with a copy of your insurance plan, including the specific language regarding your benefits and coverage.
- Document all discussions. Just as your discussions with your providers are important to document from a health perspective, it is equally important to document any discussions with your insurance company. Record the names, dates, and details of any discussions with a representative from your insurer. You may need to rely on this information later on in the case of a denied claim or appeal.
UNDERSTAND YOUR OPTIONS
- Know your history. Insurance coverage can often hinge upon past diagnosis and treatments that you have received. To best understand the options available to you and to discuss those with your insurer, develop a personal medical record to document your past diagnoses and treatments. Use online tools available at places like www.myhopefuljourney.com to help you organize your history.
- Avoid denied claims. In some cases denied claims are denied for simple reasons, such as missing data. Be proactive to ensure that you do not receive a denial because of an administrative error. Check to make sure that your pre-authorization requests include accurate patient information. You can also ask your doctor or clinic to double check diagnosis and procedure codes for accuracy in billing.
KNOWING WHEN TO APPEAL
- Learn the process. Every plan has a documented appeals process that you must follow to the letter in order for your appeal to be considered. Upon receiving a denied claim, ask your insurance company for written information on how to appeal a decision on a claim.
- Know the timeline. Often times you may only have a limited time from the date you had the procedure to get an appeal under way – in some cases, as few as 60 days. Act quickly to ensure your appeal is received in time. You can also consider entering a complaint via telephone to register your appeal, thus allowing for more time to develop the written package.
- Types of appeals. You can file an internal appeal of an insurance denial or request an exemption of benefits:
- An internal appeal is to the insurer itself. This is a request to ask the insurer to reconsider its decision. Please refer to the Fertility Within Reach Insurance Appeals Guide for more information on conducting an internal appeal.
- An exemption of benefits request is made to the insurance account manager assigned to your employer, asking for an exception to provide you coverage despite a lack of benefits.
- An external appeal is to your state department of insurance or other governing body. External appeals are filed when the internal appeal process is denied. If the external appeal is determined in your favor, your insurance company cannot deny your claim.