Thursday, December 10, 2009

Gift of the Magi

My husband's insurance is my primary, mostly because they have infertility coverage. Which is to say, they cover most (but certainly not all) medical expenses related to infertility consults, monitoring, and procedures. Combined with the cost of drugs, we are still on the hook for about $6-7K per cycle after the insurance company bends the clinic over the table, or vice versa (hard to know who's taking it worse in the economics of hospital billing and insurance claims within the health care arena anymore -- although the patient in this ménage à trois never gets a courtesy reach-around). It turns out that, after careful examination of the last 6 months worth of insurance claims, my secondary insurance through my employer actually covers a limited number of infertility medical claims as well. Well, slap my ass and call me Sally. How's about that?

I called every number on the benefits website and got transferred 67 times to investigate whether I might have any specialty pharmacy coverage, or discounts that must be requested...and, no. I am signing up for some oddly vague "ParentSteps" infertility partner program that apparently negotiates discounts with clinics including mine; we'll see how it goes after I receive my handy-dandy password to sign in and navigate that likely dead end.

Here's where my detective work gets all kinds of awesome: my employer's insurance will pay for RE consults and IUI, but not for IVF or any related medical/laboratory claims. Okay, fine. But....they provide full coverage for abortion, tubal ligation, and vasectomy. ASSHOLES.

The end.


bunny said...

SUCH assholes. What kind of assholeish criteria can they even be using?

ASP said...

Isn't that a great approach? Pay for people to abort babies (I'm pro-choice, btw) and not help those that would give anything for one? Stupid. I'm happy that you're getting stuff ready for your next cycle even if navigating the world of insurance is a complete pain in the bunghole! Exciting stuff.

jenicini said...

Yep. A-hole-a-rama.

JB said...

My company is owned parentally by United Health Group, and I unfortunately know what shitty criteria they used to judge coverage. First, whatever your level of coverage, the goal for every medical reviewer (MDs who trained to "first do no harm") is to deny as many claims as possible, irrespective of legitimacy. In fact, medical reviewers' promotions and bonuses are directly tied to their denial rate (higher rate = more job security and bigger paycheck). The same way the the rest of corporate America celebrates with office parties after a big sale or a project completed, medical reviewers pop champagne corks when they reach milestones in number of denied claims because it means individual promotion and company savings.

Second, there are entire corporate units dedicated to investigating patients' medical histories when expensive claims are submitted. Got cancer? Don't be surprised to learn that your coverage is dropped AND you have to pay back benefits received if you A) signed up for a plan that required a physical and medical disclosure and B) the insurance detectives found an old claim from 1992 under a different plan for a tonsillectomy that you forgot to disclose. Denied! This is how they drop people who are covered when they get sick.

Lastly, they set up algorithms for coverage that hedge their bets on the cheapest payouts except where reimbursement will protect their profit margin. Diabetes, cardiovascular, and obesity claims get paid because hospitals and patients pay for these disease-related procedures and LOTS of people have them. But with pregnancy and birth costs, it makes sense that paying for an abortion is hella cheaper than 10 months of prenatal care and 18 years of pediatric care. I'm pro-choice as well, but this is a business decision by insurers to enhance the profit margin that unfortunately can influence women's reproductive options in a quasi-political way (it's fun when it butts heads with moderates/conservatives in the current health care reform debates over abortion coverage restrictions -- the politicians LOVE the money insurers pay them over and under the table, but they want to appear strong on anti-choice legislation...I bet the farm on "money talks"). It's an open secret that women are over-charged into the double digits with extra premiums versus men, and that pregnancy and miscarriage are considered by some insurers to be exempt preexisting conditions. I recently read about a woman who was denied coverage because her husband had been diagnosed with infertility, even though the plan she was trying to buy didn't even cover infertility therapy.

Drug companies do the same thing. The more life-saving a drug is, the harder they try to jack up the price and keep market exclusivity. Thankfully the FDA busts up these operations when they can. A company in Chicago (Ovation) had the market cornered on a life-saving drug for infants born with heart defects, a drug that is a safer and effective alternative to a risky surgery. They bought out their sole competitor and raised the price on both drugs 400%. Needless to say, they are being class action-sued and fined by the FDA. If not, I'm sure some poor parents of dead babies would be getting some vigilante justice.

Pundelina said...


I hate this "the goal for every medical reviewer ... is to deny as many claims as possible, irrespective of legitimacy." Hate hate hate, it's so fucking wrong.

It's great that you found some extra coverage through your plan though - good luck getting value out of it.