VENT: I hate insurance!

[heatherj9603]

my husbands SA was schedule for tomorrow but just I had to cancel it because we can't afford the out of pocket expense right now. Our issursnce is covering all my testing. The ultrasounds, blood work, doctors visits. But a stupid little sperm test isn't covered! Our plan was to use our flex spending card, but now we are about to max it out to pay my upfront 20% on my surgery in March.  So add that to the two weeks unpaid I have to take off from work, we can't afford the $150 test right now. 

we will probably wait Til May to test, since that's when we will start to try again. I just wish insurance was better about IF coverage. 


Eta: I meant to put this in 3t. If someone csn direct me how to do thst or how to delete this post, or if an admin can do it for me, that would be great. 

[clecyclist]

Ask for the diagnosis code and procedure code they're trying to bill for the semen analysis. Normally insurance riders will cover infertility testing but not treatment. If the diagnosis code has a "V" in front of it, they're trying to bill it as routine, or if the diagnosis code is for infertility - it will deny.

Sorry you're having such difficulty with insurance, I hope something works out.

Source: I used to work for a BEEG health insurance company

[heatherj9603]

Jan 27, 2015 11:47:55 GMT -5 clecyclist said:

Ask for the diagnosis code and procedure code they're trying to bill for the semen analysis. Normally insurance riders will cover infertility testing but not treatment. If the diagnosis code has a "V" in front of it, they're trying to bill it as routine, or if the diagnosis code is for infertility - it will deny.

Sorry you're having such difficulty with insurance, I hope something works out.

Source: I used to work for a BEEG health insurance company

Our insurance considers it a procedure. So unless he's met his 750 deductible, they won't cover it. My dh has only used our insurance once when he broke his foot (besides going to a dr for a bad cold or sinus infection) where as my ultrasound and blood work was considered a test, so it was covered even before my deductible. 

We Have blue cross through my husbands company (not obamacare blue cross) 

[ghostmonkey]

Jan 27, 2015 11:53:31 GMT -5 heatherj9603 said:

Jan 27, 2015 11:47:55 GMT -5 clecyclist said:

Ask for the diagnosis code and procedure code they're trying to bill for the semen analysis. Normally insurance riders will cover infertility testing but not treatment. If the diagnosis code has a "V" in front of it, they're trying to bill it as routine, or if the diagnosis code is for infertility - it will deny.

Sorry you're having such difficulty with insurance, I hope something works out.

Source: I used to work for a BEEG health insurance company

Our insurance considers it a procedure. So unless he's met his 750 deductible, they won't cover it. My dh has only used our insurance once when he broke his foot (besides going to a dr for a bad cold or sinus infection) where as my ultrasound and blood work was considered a test, so it was covered even before my deductible. 

We Have blue cross through my husbands company (not obamacare blue cross) 

If it applies to his deductible, then they are covering it, but they are not paying for that particular claim.

[heatherj9603]

Jan 27, 2015 12:31:38 GMT -5 ghostmonkey said:

Jan 27, 2015 11:53:31 GMT -5 heatherj9603 said:

Our insurance considers it a procedure. So unless he's met his 750 deductible, they won't cover it. My dh has only used our insurance once when he broke his foot (besides going to a dr for a bad cold or sinus infection) where as my ultrasound and blood work was considered a test, so it was covered even before my deductible. 

We Have blue cross through my husbands company (not obamacare blue cross) 

If it applies to his deductible, then they are covering it, but they are not paying for that particular claim.

Yes if he had met his deductible it would be covered. But just annoying that his non invasive procedure has to be paid in full out of pocket, where as my blood work and ultrasound s covered even before my dediuctible. Just so backwards. 

[clecyclist]

Jan 27, 2015 12:50:39 GMT -5 heatherj9603 said:

Jan 27, 2015 12:31:38 GMT -5 ghostmonkey said:

If it applies to his deductible, then they are covering it, but they are not paying for that particular claim.

Yes if he had met his deductible it would be covered. But just annoying that his non invasive procedure has to be paid in full out of pocket, where as my blood work and ultrasound s covered even before my dediuctible. Just so backwards. 

If you were paying for the procedure out of pocket (no insurance involved) it would cost a lot more than 150 dollars. It kind of sounds like your deductible has been met, but his has not. Sorry if I'm wrong on that last part. 

[heatherj9603]

Jan 27, 2015 12:56:47 GMT -5 clecyclist said:

Jan 27, 2015 12:50:39 GMT -5 heatherj9603 said:

Yes if he had met his deductible it would be covered. But just annoying that his non invasive procedure has to be paid in full out of pocket, where as my blood work and ultrasound s covered even before my dediuctible. Just so backwards. 

If you were paying for the procedure out of pocket (no insurance involved) it would cost a lot more than 150 dollars. It kind of sounds like your deductible has been met, but his has not. Sorry if I'm wrong on that last part. 

Nope mine has not been met. That's what is so confusing. All of my stuff is covered but his isn't? I'll meet mine once I have my surgery, but for now it still shows $750.  i called and they said they don't consider an SA a vital diagnostic so it's not covered. Where as my stuff my dr can get around. They were not going to cover having my tubes checked, but now that Im having my fibroid surgery, my dr said she can deem it medically necessary to check for scar tissue so they will have to cover it. But the ultrasound, blood work, and multiple check ups were all covered even with no deductible being met. 

Maybe it's because Im still at my obgyn and his test is at the fertility clinic? 

[clecyclist]

I'd guess this may be a diagnosis code/procedure code issue.

[pismoduo]

Jan 27, 2015 13:06:54 GMT -5 heatherj9603 said:

Jan 27, 2015 12:56:47 GMT -5 clecyclist said:

If you were paying for the procedure out of pocket (no insurance involved) it would cost a lot more than 150 dollars. It kind of sounds like your deductible has been met, but his has not. Sorry if I'm wrong on that last part. 

Nope mine has not been met. That's what is so confusing. All of my stuff is covered but his isn't? I'll meet mine once I have my surgery, but for now it still shows $750.  i called and they said they don't consider an SA a vital diagnostic so it's not covered. Where as my stuff my dr can get around. They were not going to cover having my tubes checked, but now that Im having my fibroid surgery, my dr said she can deem it medically necessary to check for scar tissue so they will have to cover it. But the ultrasound, blood work, and multiple check ups were all covered even with no deductible being met. 

Maybe it's because Im still at my obgyn and his test is at the fertility clinic? 

The bolded, combined with the fact that it sounds like at least some of your testing is/was/could be billed as a follow-up or diagnostic associated with a necessary surgery. If your doctor is linking your testing to the diagnosis or follow-up for your fibroid surgery, it's probable that the insurance company is accepting it as that instead of as fertility treatment/diagnosis. Whereas his claim is coming from a fertility clinic AND isn't being linked to a medically necessary procedure.

[heatherj9603]

Jan 27, 2015 13:42:11 GMT -5 pismoduo said:

Jan 27, 2015 13:06:54 GMT -5 heatherj9603 said:

Nope mine has not been met. That's what is so confusing. All of my stuff is covered but his isn't? I'll meet mine once I have my surgery, but for now it still shows $750.  i called and they said they don't consider an SA a vital diagnostic so it's not covered. Where as my stuff my dr can get around. They were not going to cover having my tubes checked, but now that Im having my fibroid surgery, my dr said she can deem it medically necessary to check for scar tissue so they will have to cover it. But the ultrasound, blood work, and multiple check ups were all covered even with no deductible being met. 

Maybe it's because Im still at my obgyn and his test is at the fertility clinic? 

The bolded, combined with the fact that it sounds like at least some of your testing is/was/could be billed as a follow-up or diagnostic associated with a necessary surgery. If your doctor is linking your testing to the diagnosis or follow-up for your fibroid surgery, it's probable that the insurance company is accepting it as that instead of as fertility treatment/diagnosis. Whereas his claim is coming from a fertility clinic AND isn't being linked to a medically necessary procedure.

Hmm makes sense. I booked the appointment before I found out I needed surgery anyway. So it's probably better to wait. I'd hate to spend that money then have my surgery and find out my tubes couldn't be saved or something. 

[ghostmonkey]

If it is not covered, then your deductible amount is completely irrelevant as it will be denied and not applied to that.

If it applied toward your deductible amount (which is what you said) it is covered, but again, they don't pay it until after you hit a certain amount.I don't think you fully understand what it means if something is covered.

Where you are getting tested and where he is tested is irrelevant as well. For one you are two separate patients, so his test is not linked to you and anything you are having done.

[getzystark]

Jan 27, 2015 13:49:15 GMT -5 ghostmonkey said:

If it is not covered, then your deductible amount is completely irrelevant as it will be denied and not applied to that.

If it applied toward your deductible amount (which is what you said) it is covered, but again, they don't pay it until after you hit a certain amount.I don't think you fully understand what it means if something is covered.

Where you are getting tested and where he is tested is irrelevant as well. For one you are two separate patients, so his test is not linked to you and anything you are having done.

So much this^^

Something being "covered" and your OOP expenses are two completely different things. When you're saying they "covered" something, I believe you're describing that insurance covered whatever the test/visit/procedure was at 100%. Things can still be "covered" by insurance but at a specific percentage (i.e. 80%, meaning your OOP is 20%). That means it was still "covered" but you ended up with some OOP payment needed. Typically, you need to meet your deductible on non-routine care first, before insurance will pay out for things that they cover. Most insurance companies do not require your deductible be met when you are having routine care done (like wellness exams and Paps) so that's where things get confusing.

[sunfrogger88]

PP is 100% right. I don't think I can add anything else because getzy covered it all.