Insurance Benefits

Insurance Benefits is a complex journey that both our patients and our staff travel through daily. Sometimes that path is clear and easy, and other times it can be a journey fraught with pitfalls. We hope this post helps explain how those challenging journeys can be created and how to navigate them together to optimize our journey together.

Insurance companies have two main contact points: members’ benefits and claims and adjudication. Member benefits focus on what benefits are available for our patients, while claims and adjudication determine what will be paid to our clinic for the services completed. These two departments do not work together and rarely, if ever, communicate with each other.

Member Benefits

Member Benefits is there to help patients understand what benefits they have access to and how to access those benefits. This is an important function for patients at the start of their journey of finding an IVF clinic to work with. One of the most important pieces of information you typically do not get from member benefits is the criteria for those benefits. For example, you may have the benefit of embryo biopsy, but there may be criteria in order to access that benefit. That may include a genetic screening of the patient and their partner to determine if both are carriers of a genetic disorder. Another example we commonly see is the member having the benefit of ICSI (Intracytoplasmic sperm injection), but only after the male partner has a semen analysis, and that analysis falls into the range that the insurance company deems ICSI necessary. The difference between having the benefit and being eligible for the benefit is not handled by member benefits but instead by the claims and adjudication department.

Claims and Adjudication

Claims and Adjudication is the primary department the clinic works with. This department handles the approval of claims to be processed and paid. The primary focus is not so much on the benefits that are available to the patient but on the eligibility of the patient for those benefits. This department will look at medical records for not only the procedures performed, but for medical records that support the eligibility for payment of the procedures performed. For example, we may provide appropriate supporting documentation that a biopsy was performed, but if they do not have access to the genetic screening of the patient that notes both partners carry the same genetic disorder, they will not pay for it. At times, we may need to enroll the patient to call their insurance on our behalf if we have all of the documents required for payment but the insurance company is not paying, as that could result in unnecessary out-of-pocket expenses for the patient.

We hope this helps explain some of the pitfalls we can experience when working with your insurance company along your fertility journey. For more information on your specific insurance, ask our team, and expect us to guide you every step of the way.