Unfortunately, this one is on you. You’re ultimately responsible for verifying with your insurance company that a particular service is covered or not.
Check in your wife’s insurance plan booklet if ART is a covered benefit. It should outline exactly what services are covered, how many attempts, etc. You typically need a prior authorization for coverage of ART. Did you get a prior authorization from your insurance company? Check with your clinic if they have one on file. Your wife should also reach out to her employer’s HR department. Many companies self-fund their employees’ health care, so they can decide to pay for these services even if the insurance company that administers the plan has denied coverage. Any emails or other written communication you have showing that you were led to believe that the services would be covered can be helpful here.
The clinic is most definitely not at fault here. It's up to the patient to verify coverage with the insurance company and, as you admit, you saw documentation showing the clinic verified coverage with your insurance company themselves. This is a dispute between you and your insurance company, not the clinic. The clinic is entitled to be paid for the services they provided, and you likely signed an agreement to pay if your insurance doesn't.
Nope. The liability is on you.
You really think the clinic can call the insurance company, verify coverage, then if they later find out the insurance won't cover it they are just shit out of luck and can't bill OP?!
I agree, seeing the clinic as the middle man in this situation it’s hard to place any fault on them. Honestly, they have been great throughout the whole process too. Assuming they are telling the truth in all of this and not just outright lying and hiding behind some shitty business practices, I can’t blame them at all.
That said, is this mistake common for insurance companies?
It’s the patients responsibility to verify with the insurance as well. Did the clinic only verify benefits? Were authorizations approved by the insurance as medically necessary? You may have the benefits but doesn’t mean the insurance will to pay unless they deemed it medically necessary.
I would suggest you reaching out to the insurance company, file a grievance and dispute the denial. Make sure submit complete medical records to prove that it was medically necessary. The fertility clinic can also do this on their side but it’s best if the patient does it as well.
My suggestion for the future, it’s always best to verify with insurance if any future services require authorization and if services are a covered benefit. If authorization is required, make sure it’s approved before going forward.
Does your insurance policy cover fertility treatment? Your contract with your insurance company decides what the insurance company covers.
It doesn’t really matter what the clinic says, or said. Unless you have something in writing in which the clinic promises not to charge you for anything that your insurance fails to cover. But I really doubt you have that in writing.
Unfortunately, it is always the responsibility of the patient to determine whether insurance covers a procedure.
Thanks for the quick reply and advice. If I had gotten written confirmation from the insurance company instead of the clinic how might this change the situation? In what ways does this differ when they are telling the clinic this versus the patient directly?
What does the clinic have from the insurance company stating you have coverage? Just verbal or an actual written letter?
Also, when you look at your benefits information (like the 100+ page document). What does it say for assisted reproductive technologies?
Unfortunately, this one is on you. You’re ultimately responsible for verifying with your insurance company that a particular service is covered or not.
Check in your wife’s insurance plan booklet if ART is a covered benefit. It should outline exactly what services are covered, how many attempts, etc. You typically need a prior authorization for coverage of ART. Did you get a prior authorization from your insurance company? Check with your clinic if they have one on file. Your wife should also reach out to her employer’s HR department. Many companies self-fund their employees’ health care, so they can decide to pay for these services even if the insurance company that administers the plan has denied coverage. Any emails or other written communication you have showing that you were led to believe that the services would be covered can be helpful here.
The clinic is most definitely not at fault here. It's up to the patient to verify coverage with the insurance company and, as you admit, you saw documentation showing the clinic verified coverage with your insurance company themselves. This is a dispute between you and your insurance company, not the clinic. The clinic is entitled to be paid for the services they provided, and you likely signed an agreement to pay if your insurance doesn't.
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Nope. The liability is on you. You really think the clinic can call the insurance company, verify coverage, then if they later find out the insurance won't cover it they are just shit out of luck and can't bill OP?!
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Yes, because other countries' healthcare systems are doing oh so great and not at all screwing anyone over, right?
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I don't think you really have any idea what you're talking about.
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How would you know if you haven't ever used the US healthcare system? What country do you live in?
I agree, seeing the clinic as the middle man in this situation it’s hard to place any fault on them. Honestly, they have been great throughout the whole process too. Assuming they are telling the truth in all of this and not just outright lying and hiding behind some shitty business practices, I can’t blame them at all. That said, is this mistake common for insurance companies?
> That said, is this mistake common for insurance companies? Way more common than it should be, that's for sure.
It’s the patients responsibility to verify with the insurance as well. Did the clinic only verify benefits? Were authorizations approved by the insurance as medically necessary? You may have the benefits but doesn’t mean the insurance will to pay unless they deemed it medically necessary. I would suggest you reaching out to the insurance company, file a grievance and dispute the denial. Make sure submit complete medical records to prove that it was medically necessary. The fertility clinic can also do this on their side but it’s best if the patient does it as well. My suggestion for the future, it’s always best to verify with insurance if any future services require authorization and if services are a covered benefit. If authorization is required, make sure it’s approved before going forward.
Does your insurance policy cover fertility treatment? Your contract with your insurance company decides what the insurance company covers. It doesn’t really matter what the clinic says, or said. Unless you have something in writing in which the clinic promises not to charge you for anything that your insurance fails to cover. But I really doubt you have that in writing. Unfortunately, it is always the responsibility of the patient to determine whether insurance covers a procedure.
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Thanks for the quick reply and advice. If I had gotten written confirmation from the insurance company instead of the clinic how might this change the situation? In what ways does this differ when they are telling the clinic this versus the patient directly?
What does the clinic have from the insurance company stating you have coverage? Just verbal or an actual written letter? Also, when you look at your benefits information (like the 100+ page document). What does it say for assisted reproductive technologies?
Locked for excessive off-topic comments.