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Despite being recognized as a disease by major health organizations, infertility is infrequently covered by insurance providers. Because it’s not mandated by many states, it’s often left up to employers to decide whether or not to include it for their workers.
And though more companies are embracing employee wellness programs and opting into fertility coverage, we have a long way to go towards a system that truly recognizes fertility care as healthcare.
Until then, the reality is that while most fertility patients have coverage for diagnostic testing, few patients are fortunate enough to have insurance coverage for their infertility treatment — and must pay out of pocket or go into debt to build their families.
But those lucky patients who do have insurance coverage still have a minefield of hidden costs to navigate, some of them quite costly.
The information patients need to avoid those financial pitfalls is also not readily available or easy to understand, which means many get in too far before they learn about these surprise costs.
At CARE Fertility, we believe that informed patients have better outcomes — and that includes being informed about the financial aspects of your care.
If you’re considering seeing a fertility doctor and plan to use insurance, there are a few things you should know before you schedule that first appointment.
Finding a doctor who’s “in-network” isn’t enough.
When patients first decide to see a fertility doctor, their first step is often to search for one who’s considered in-network by their insurance provider. They’ll often be drawn to a particular physician or clinic because it looks like they’re in-network.
But this is not the green light it may seem to be. If the doctor or the clinic is in-network, your first appointment will likely be covered. But what happens after that?
In the insurance system, medical providers can either be physicians, facilities like hospitals or ambulatory surgical centers, or laboratories. All three of those different entities can bill insurance, and can therefore be providers who are in-network or out of network.
For insurance to fully kick in, it’s not just the doctor who needs to be in-network — the facility and the lab must be, too.
Because if you decide to move forward with treatment, there will be additional, separate charges beyond the procedure itself — fees for the laboratory, anesthesia, and the facility where the procedure will take place.
A patient who needs in vitro fertilization (IVF), for example, will incur fees related to the use of the procedure room, along with the anesthesia medicines, IVs, and other supplies.
Many clinics also bill for the anesthesiologist as a separate fee, and that may not be readily apparent to the patient up front. If the anesthesiologist turns out to be out of network, the patient will have to foot the bill.
Not all facilities will be covered, even if they’re in-network.
So you checked with your new clinic and the physicians, the anesthesiologists, the facilities they use, and the laboratories they work with are all in-network. You’re in the clear, right?
Not so fast. If your new fertility clinic will be performing your procedure on-site, there are more questions to ask.
Some fertility clinics perform egg retrievals in nothing more than a physician office setting. Some have their own standalone facilities that allow them to perform a variety of surgical procedures on-site instead of requiring patients to visit a hospital.
But if that facility isn’t an accredited Ambulatory Surgical Center (ASC), even patients with stellar insurance will still have to cover that facility charge out of pocket.
Just like doctors must have a license to practice medicine (and an insurance company won’t pay them if they don’t!), facilities must undergo an accreditation process in order to bill insurance.
Facilities that aren’t accredited may look exactly the same to a patient, as fully equipped operating rooms with all the bells and whistles. The fertility clinic may even call it something like an “ambulatory surgical setting.” But the medical provider can’t legally call it an Ambulatory Surgical Center or bill insurance for the use of the facility if it’s not accredited.
They can still legally bill the patient, of course.
Accreditation is also important for patient safety. It means the facility meets certain standards for surgical care. CARE Fertility was the first to open an ASC in North Texas in 1996 and it has been accredited since.
In-network or not, accredited or not, all of these various fees can also be manipulated in different ways. Some fertility doctors keep their medical care fees low on the front end to seem more affordable, and then profit on higher facility fees on the backend. If insurance doesn’t cover that facility for one reason or another, that can be a financial shock for a patient, discovered only at the last second.
Even when they’re covered, medications add up.
The medications required by many fertility treatments add an additional layer of financial complexity, and not just because they can be expensive on their own.
Across our healthcare system, it’s not uncommon for the same procedure to cost exponentially more when billed to insurance instead of charged directly to the patient on a cash-pay basis. Medication costs are no different.
Hypothetically, if an infertility patient with insurance needs $5,000 worth of medication, the pharmacy may charge the insurance company as much as $10,000 or $12,000 for the same medication.
At first glance, this may not seem like an issue for patients. So the insurance company has to pay more — that’s their problem, right?
But many insurance policies come with a lifetime limit on what they’ll pay out for certain types of medical care. Medication is one. If a patient’s lifetime maximum on medication is $10,000, they could go through that in one IVF cycle, forcing them to pay for medication out of pocket if they need a second cycle.
Ultimately, someone always bears the costs of our broken healthcare system — and all too often, it’s the patient.
This system also allows for some surprising and ethically ambiguous financial loopholes.
Under Texas law, you can’t dispense medication unless you’re a pharmacist, so fertility clinics here don’t dispense medication and therefore can’t profit from medication sales. It’s also illegal for doctors to receive a kickback from pharmacies for referring patients to a particular one.
What’s not illegal, however, is for doctors to have an ownership stake in a pharmacy and get a share of profits. They’re then incentivized to send patients there, even if lower prices can be found elsewhere. Though this creates a conflict of interest, it unfortunately does happen.
Patients must be their own advocates.
When evaluating a potential fertility doctor, don’t take the office’s word for it if they say they’re in-network. Ask multiple follow-up questions:
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So the doctor is in-network. But what if I need surgery?
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Is the facility in-network?
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If you have an ASC, is it accredited?
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Are the anesthesiologists you work with in-network?
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Are the labs you use in-network?
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What should I expect to pay for medications?
At CARE Fertility, our doctors, clinic, facility, anesthesiologists and labs are in-network with nearly all insurance providers. For non-insurance patients, the cost of the anesthesiologist is bundled into the fee for IVF so there are no separate, surprise charges. And our Ambulatory Surgical Center has been fully accredited since we opened its doors in 1996.
We also do our due diligence at the beginning of every new patient relationship to verify insurance coverage and explain the costs from day one. We never want patients to be surprised.
We believe all fertility clinics should either participate fully with insurance plans, so that every aspect of a patient’s care is in-network, or be very transparent with patients from the beginning that there will be extra costs.
But the burden ultimately rests with patients to fully understand the financial costs associated with their care — even, or perhaps especially, when they have insurance.
As a patient, it’s up to you to advocate for yourself and be actively involved in decisions about your care, whether medical or financial in nature.