insurance question
8 Replies
Tink - November 8

a quick question, - but i was unclear on ins coverage during my first 2 IUIs. i paid for them out of pocket- about $425 each. but i later got the insurance cleared up and learned that they do cover IUIs. so i had to go submit those two IUIs as claims to the ins directly myself. I expected to be reimbursed the $850 from ins. Problem is, the doc has a contract with them, so they had to pay him directly instead of me. and they had to pay him the 'contracted' rate he had negotiated with them. which was about $80 per IUI!!! or $158 total (instead of $850)--that is nuts. so he is willing to only accept $80 per IUI if the insurance is paying, but expects me to pay $425. what a racket. anyways-, so the doc only is going to get paid $158 instead of $850. problem is, i have to get him to try and reimburse me the original $850. i don't know that he is 'required' to. ethically you would think he would. i at least am entitled to the $158 that insurance reimbursed him. but i expect more. anyone else come up against this before? i called today and the ins lady at my RE's office said they would have to wait until they got hte actual check from insurance (which they should already have, claim was processed on 10/24)....then review the explanation of benefits, before they can tell me what/how much i will get reimbursed. i am hoping it is all of it, minus the copay. but who knows. my DH will go nuts if they don't give it all back. they should. but since they already have my money, they may not want to. i don't want to rile them up either too much, in case i need to continue treatment there. any thoughts? anyone else experience anything similar?


linds99 - November 8

From what I understand, your doctor is "LEGALLY" binded to repay you the amount you paid him for the IUIs since you have proof of coverage at the time of the IUIs and YOU HAVE INSURANCE. The INSURANCE will pay him his mandated amount. If you were not insured at the time, that is the fee he would normally charge an uninsured patient, but you have insurance. But this is not the case. You need to promptly write his office a poignant letter demanding full refund minus the amount the insurance paid and your copay. And do this quickly. Threaten legal action if you have to. But I think he has 60-90 days to repay you the amount.


mommywannabe - November 8

Can I ask you what insurance company you have? I work for a Health Insurance company and might be able to help you.


mommywannabe - November 8

I agree with linds99.


Ann1 - November 8

It depends on whether your dr has a contract with your insurance company. If he is an "in network" physician for your insurance company, he owes you back everything less your required copay amounts. If he is an "out of network" physician for them, he will likely accept the insurance from them (although he may require you to pay him up front) but you would be liable for the difference between the insurance payment and the total bill. Hope this helps!


Tink - November 8

Linds- Ann- thanks for the info- he is an in-network for me. mommywannabe- I have Cigna. I am on the plan where my in network stuff is covered 100%.

i am hoping this won't be a fight and that they will do the right thing, especially if they are supposed to legally, but as well as ethically. heck, they'll probably get that money back when i have to use it next cycle if i don' t get my miracle this time. i see them on friday for progesterone check, so i'll inquire again then. thanks for the help ladies!


Ann1 - November 8

Tink, I've done this before with the insurance. They paid me back as soon as the check cleared for them. The dr won't want to mess up the contract w/the insurance company. I would be surprised if you have a problem with it. Also, just because it shows your claim was processed at cigna doesn't mean that they have printed a check and mailed it to the dr. The insurance companies are notoriously slow paying bills!


mommywannabe - November 8

Amen Ann1. I work for one and know they at least wait 30 to 45 days to pay providers so you are VERY correct on that. Tink I am trying to get with one of the contractors here (Anthem) and find out what we do in this situation so that I can give you a better response. I honestly think if your doctor is reputable that he will pay you all your money back less the co-pays. I'll know more tomorrow.


Tink - November 9

Ann and Mommywannabe- thanks for the info, that takes my stress level down a bit and makes me feel a ton better and last thing i need now is stress in this 2WW! i appreciate it so much! my RE is very reputable, in fact he was listed as one of top 10 REs in the country in 05 and 06 (we are in dallas). he is pretty well known (has a website called fertility journey- james douglas). i am hoping he won't want to mess with his reputation or his ins contract. (or his ins person won't anyways, he probably has no clue about my ins case). again, thanks for the info. claim was received by ins on 10/20, processed on 10/24. they said about 30 days for payment, so i am hoping just before thanksgiving (next week?) maybe the RE will get payment and we can settle this! ;)



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