Budgeting Your Fertility Journey

By : David Jaramillo

budgetingInsurance and Billing Frequently Asked Questions


1. Understand the difference between HMO and PPO plan.

A PPO (preferred provider organization) is a plan that specifically allows for self-referral to a specialist physician. This does not mean that all future services with that specialist will be covered, but you will be able to visit them for consultation without a referral from your primary care provider or Ob/Gyn. An HMO (health maintenance organization) is the type of plan that requires you to obtain a referral to even see a specialist physician. Furthermore, all services performed by the specialist will require a current authorization prior to obtaining the service or procedure.

2. Understand your benefits and the monetary limitations that they have.

Many plans offer infertility benefits but have very low monetary limits. This is most often a function of the number of employees. For example, in the Bay Area, larger corporations such as Google, Salesforce and Bank of America offer very robust plans with coverage from 15,000.00 to an unlimited lifetime maximum in some cases. Other smaller corporations will have plans with much less of a benefit package. Many plans ONLY cover diagnostic testing to try and determine the underlying cause of infertility (laboratory testing, hysterosalpingogram, surgery), but no benefits for actual fertility treatment (insemination or in vitro fertilization services). In addition, medical procedures and prescription benefits can be either combined under a single coverage limit, or separated with two individual policies and monetary limits.

3. Who determines procedure & diagnosis coding?

Most medical conditions and procedures have codes associated with them (procedure and diagnosis codes). This coding must reflect the purpose for which a visit or procedure occurs.
Diagnosis and procedure codes are provided by the Physician when billing a service through an insurance carrier. ONLY a physician can review and change this coding. Further, the insurance company has the right to audit a chart and reverse a decision on payment if they feel that coding is fraudulent. Therefore, just because a claims person indicates that a given procedure could possibly be paid if re-coded does not mean the original coding given is incorrect or can be legally changed.

4. What is the difference between a Co-pay, Co-insurance, a Deductible, and Out-of-pocket expenses?

Typically a co-payment refers to the payment accompanying any office visit (i.e. $10.00 copay). The term co-insurance refers to the percentage of a total charge that the patient might be responsible for (i.e. insurance pays 80% and patient pays 20%). A deductible usually refers to a calendar patient responsibility such as $500.00 per calendar or fiscal year. The deductible renews annually and must be met by the subscriber before anything is paid by the Insurance carrier. The out-of-pocket amount is a monetary limit placed on most plans by the carrier. Once met, the carrier will then pay all further claims at 100% up to any benefit limitation (for example the lifetime maximum on an insurance benefit). Some plans do not include the annual deductible into the out of-pocket maximum while others combine the two costs.

5. What does it mean to coordinate my benefits?

In some cases, you may have a primary AND secondary insurance plan. If active coverage exists under more than one carrier, it is important to provide your physician’s office with
both plans. Your physician’s office is required to bill the primary carrier first, regardless of whether the fertility benefit exists. In the case of a denial from the primary plan, the biller can
then coordinate benefits through the secondary plan with a copy of the Explanation of Medical Benefits for payment.

AUTHOR BIO

David Jaramillo is the Financial Specialist for Lane Fertility Institute. He works to provide a high level of assistance to patients trying to navigate the complexities of fertility benefits. From insurance and billing questions, to self-pay agreements, David will work to ensure that you understand your options. The goal of David’s position is to provide patients with a
resource and advocate within the practice. We aim to increase your satisfaction and reduce your anxiety during this fertility experience.

David has over 30 years of experience working in health care finance. He spent over a decade as the financial specialist at the UCSF Center for Reproductive Health where he pioneered the systems that are still used there to this day. He looks forward to helping you navigate your fertility experience.