"Inappropriate" Unlimited Diagnostic Coverage with Limited Treatment Options

Offering diagnostic benefits without all treatment options does not allow you the opportunity to attempt procedures leading to pregnancy. Also, insurance carriers who reimburse for unlimited diagnosis but only some treatment options (like tubal surgery) expose themselves to increased and unnecessary costs. Patients will gravitate toward reimbursable procedures even if those procedures have little chance of success.

Insurance carriers should provide patients with a limited diagnosis benefit and free up insurance dollars to cover all potentially useful treatment procedures, such as intrauterine insemination (IUI) and in vitro fertilization (IVF). Patients do not need unlimited diagnostic coverage. Once diagnosed, patients need coverage for all treatment procedures that will potentially enable them to become pregnant.

For example, a patient with blocked fallopian tubes may have 2 choices to attempt pregnancy: tubal reconstructive surgery or IVF. While IVF may be the treatment of choice, the insurance company will only reimburse for tubal surgery, which can be less effective and require a greater disruption of lifestyle for the patient. In addition, inpatient tubal surgery may cost more than IVF. Patients may repeatedly attempt ineffective and expensive tubal surgery because insurers do not effectively manage their infertility benefit.

Many self-insured employers provide inadequate infertility treatment coverage. But employees can be a catalyst for change. For example, an infertility patient employed by a large self-insured manufacturing company in the Midwest wrote to her third-party administrator and requested her current infertility benefits. When the administrator informed the patient in writing that her plan did not reimburse for fertility treatment, the patient approached her Human Resources Department and asked for an exception to her denial. Human Resources contacted the infertility clinic's financial counselor and discussed adding an infertility benefit to the company's current coverage. As a result of a meeting between the infertility patient's employer and representatives of the infertility center to discuss potential benefits, the employer added a $25,000 infertility diagnosis and treatment benefit for 6,000 employees nationwide to become effective the following year. The Human Resources manager commented during the meeting that adding an infertility benefit that includes assisted reproductive technologies is "pro-family and the right thing to do for our employees."

Employees and self-insured groups partnering with medical providers can increase benefits and contain costs. Employees can help their self-insured employers see how changes to their current benefits can better serve everyone.

Many traditional insurance companies reimburse for unlimited infertility diagnosis and tubal surgery but do not reimburse for assisted reproductive technology procedures because they assume that paying for these procedures will increase overall costs.

But traditional insurance carriers can limit their financial liability and increase subscriber benefits by providing a limited diagnosis and treatment benefit that includes assisted reproductive technology procedures. For example, in 1988 an infertility center approached a large traditional insurance carrier in the Midwest. As partners, they created a $15,000 infertility diagnosis and treatment benefit that included assisted reproductive technology procedures. They based the benefit on proper coding and a willingness between the infertility center and the insurance carrier to work together. The insurance carrier recognized that a limited benefit would limit their financial liability. They also discovered that they could offer the new benefit with no rate increase in premiums. In other words, subscribers received assisted reproductive technology benefits at no additional cost. The insurance carrier commented that they were interested in stopping patients from having numerous and ineffective tubal surgeries. They continue to offer this benefit to over 1 million subscribers today.

This example demonstrates how a for-profit business evaluated a current benefit, sought input from infertility providers, and increased benefits while maintaining costs. The decision to increase benefits was good for both the insurance carrier and the patients they insure.

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