THE INFERTILITY PATIENT AND THE INSURANCE COMPANY...THE ODD COUPLE.

Here is some advice regarding getting coverage for infertility testing. Consumers need to keep in mind that medical insurance companies are not your advocates. They make their money by keeping the premiums that you have paid, if you don't use them. Therefore, their goal is to keep as much of your money as they can (profit); and they have been doing a good job of it. Evaluation of their stock and company perfomance show that they are one of the best businesses to invest in because, despite a recession, they continue to make lots of money. That being said, here is one way that insurance companies shortchange infertility patients.

As many infertility patients know, once they determine that they have been unable to become pregnant, they need to undergo an evaluation. Also, patients undergoing higher level treatments, such as in vitro fertilization, are required to undergo testing as mandated by the FDA and CDC. In most cases, these tests are general health screening tests and not specifically infertility tests. They are tests such as infectious disease testing, hepatitis, AIDS, hormone testing, pelvic ultrasounds, etc. These are tests that are done for many reasons and for many diagnoses, not specifically or only for infertility. Coding requirements mandate that the most specific diagnosis is used when billing. Infertility, is not a very specific diagnosis. In most instances, there is a diagnosis that is a more specific illness, which as a consequence of their effect, can lead to or cause infertility. These are illnesses such as:

• irregular menstrual cycles


• polycystic ovarian syndrome


• sexually transmitted disease screening


• abnormal bleeding, endometriosis


• uterine fibroids, etc.

Make sure that your doctor or clinic is using the most specific diagnosis that they can.

In terms of insurance coverage, if you do not have infertility coverage, then insurance companies will not pay for infertility services. As mentioned above, many of the tests, if coded with the specific illness, are not infertility codes. Therefore, these tests should be covered. However, many, if not most, insurance companies will automatically flag your account if there is ANY reference to infertility. They then will deny all claims that can be related to infertility testing or treatment thereafter, including general health tests. Remember, their goal is to not pay for as much as possible and this is one way that they get away from paying for tests. Keep an eye on your EOB's, the statements you receive from your insurer that tells what they covered and did not cover. Also, check your test requisitions too and ask what diagnostic code they used. If they used an infertility code, ask if there is a more specific diagnosis code pertaining to your condition that they can use. Then if the lab test is denied, YOU need to contact your insurance company and file an appeal. It should be done in writing and keep all records of your attempts. Do not rely on the doctor's office to do this for you. Remember, you are the insurance company's client, NOT the doctor. You have more leverage than they do. Ultimately, if the insurance company denies a justified claim, that you have repeatedly appealed, you can go to the next level of appeal, which is the Commissioner of Insurance for your State and file a complaint.

Word of Caution! I am NOT advocating that you commit fraud. If there is no other diagnosis or illness that applies to your test, and infertility is the only diagnosis that can be used, then that is the correct diagnosis. In that case, the insurance company has the right to deny the claim. Do Not ask your doctor to lie about your condition by using another diagnosis code. Both you and your doctor can be criminally liable if you commit fraud. Remember, honesty is your greatest weapon when dealing with the insurance companies. They are required to be honest with you as well. If you are not honest, you have nothing to stand on to refute their denial. If you are, and your claim is legitimate, then the insurance company has to accept your claim. You are paying them for the services they have promised to provide. Be a wise and diligent consumer and make sure they are providing you with all the services you are entitled to.

HORMONE REPLACEMENT THERAPY

Five years ago, the NIH stunned the country by publishing a study regarding hormone replacement therapy (HRT). This study refuted ALL the previous studies heralding the benefits of HRT, by claiming that it increased the incidents of heart disease and breast cancer. This sensationalized conclusion led millions of women to abandon their HRT, leading to mass suffering among women. I remember seeing these headlines in very well placed articles in various newspapers. It aggravated me because I reviewed their data and found one serious flaw that should have negated all their results: their data was NOT STATISTICALLY SIGNIFICANT.

Whenever scientific studies are performed, their results are measured by various mathematical tests to see if in fact the findings are really showing what they purport to show. We call this statistical significance. Results are either statistically significant or not. There is no middle ground. The WHI authors tried to create a new term, "almost statistically significant." There is no almost. It is either yes or no. If it is not yes, then the results are not justified. Since the release of this study, multiple newer analyses of the same data have refuted the author's original claims. In addition, the average age of women in the study was 60 and a full 10 years after starting menopause. The conclusion that readers should draw, after all the recent backpedaling, is that the findings of this study from 5 years ago were incorrect and should be ignored. They also don't apply to recently menopausal or perimenopausal women.

So what do you do now?

• If a woman is postmenopausal and does not take HRT for 10 years or more after menopause, then there will be no benefit to starting. In fact, estrogen could be detrimental at that point. However, several recent studies and re-analysis of WHI data have shown, in confirmation of previous pre-WHI studies, that HRT is beneficial to women if begun at or near menopause.
• Benefits include a reduction in heart disease, cognitive function, skin health, vaginal health and bone health.
• Most significant, is a reduction in heart disease, which is the number one cause of death in women after menopause.
• In addition, the review of the data, contrary to the original WHI conclusions, is that there is a reduction in the incidence of breast and colon cancer. The studies are too numerous for me to cite here, but suffice it to say that the data is overwhelming.

I have continued to recommend HRT in my peri-menopausal and menopausal patients, despite the initial WHI broadcasts. I'm glad I did because now we know that it is protective of their health. For me it only makes sense. The most healthy, happy and vigorous parts of a women's life is the pre-menopausal days when estrogen was abundant. When women become menopausal, their health, body and mind begin to deteriorate, as a result of the lack of estrogen. In fact, estrogen is the youth hormone and should be continued. When my patients present in their 40's with peri-menopausal symptoms of irregular or abnormal periods, insomnia, difficulty concentrating or remembering, mood swings, lack of energy or general lack of well-being, that is the time that I recommend HRT. Usually, I use a low-dose birth control pill because it has sufficient estrogen and is easy to take. In women who don't have a uterus (due to hysterectomy) I give a higher dose estrogen without progesterone. At this point, it is unknown how long a woman should take estrogen. In my opinion, since the average lifetime of women is increasing, currently it is 86 years old, women should continue with the estrogen indefinitely. At some point, maybe it won't be necessary but for now, I think there is very little risk and lots of youth to gain.

CHOOSING A FERTILITY SPECIALIST

I've often been asked by patients, when and how to choose a fertility specialist. The question they have is whether to stay with their current OB/GYN physician or seek out an infertility specialist. First, if you are undergoing some evaluation and possibly treatment by a Family Practice physician or General practitioner, you're in the wrong hands. Your doctor may feel he or she can do infertility, and may have had some exposure to infertility in their training, but it was hardly enough for them to be evaluating and/or treating infertility patients. I have even had patients that were under the care of physician assistants and nurse practitioners! These are the wrong providers for your problem. Speciality care should be done by a specialist, an OB/GYN physician, Infertility specialist or Reproductive Endocrinologist, not a general practitioner. See "Infertility Evaluation" for more information.

The easy answer to the question is seek out the physician that you feel you need to see. If you want a basic level of evaluation and treatment, or want minimal intervention, then most OB/GYN physicians have adequate training and knowledge of infertility to help you. However, this varies among OB/GYN docs so make sure your doc has this knowledge. One good way of screening is to simply ask what levels of treatment they provide: Clomid ovulation induction, Gonadotropin ovulation induction or Insemination (artificial insemination)? I would choose a doc that can do at least insemination. If they don't do that, then their training and knowledge is probably not adequate for your needs. The problem with docs that only do a little, is they tend to get stuck in the little that they can do and are slow to refer you to a higher level of care. For example, a doc that can only do Clomid ovulation induction, but not insemination, tends to treat their patients for months with just Clomid, often without even doing a complete infertility evaluation to see if this is the best treatment. Clomid ovulation induction should probably not be done for more than 6 months. If your doc gives you a prescription for Clomid, that is a year's supply, and says call me if you miss your period, then you need to find another doctor. Or, if you go to your doctor with your infertility problem and the doctor sends you away with a Clomid prescription before even suggesting an infertility evaluation, then that is another sign that you need to seek out a different doctor. As a consequence, you end up losing valuable time, and money. A good OB/GYN and Infertility specialist will lay out a clear and concise plan for evaluation and treatment, and give a defined timeline for each.

However, that being said, you may also want to avoid the clinic that provides only IVF, because they will not offer other choices of evaluation or treatment. If you are just starting your infertility care and evaluation, that may be the wrong choice for you. Many large IVF clinics are like that. They only provide IVF. You want an infertility specialist that offers IVF, in addition to, a broader level of evaluation and care. Find someone who can provide all levels of infertility evaluation and treatment.

So, when should you seek a specialist? The answer is when you feel you need a specialist. For some that will be right from the start, when you realize you are not getting pregnant. For others, that will not be until they have exhausted their options with their Ob/Gyn doctors. My advice is this: if you are under 35 years old, then either a well-trained Ob/Gyn doc or an infertility specialist will do, depending on your problem. If you decide to go to an Ob/Gyn doc, then do not spend more than 6 months on a treatment plan. If it doesn't work by that time, then it's time to move on. If you are over 35, then you should go directly to see an infertility specialist, because time is working against you. Also, if you have tubal blockage, stage 3 or 4 endometriosis, a very bad semen analysis or failed four IUI's, then you should see an infertility sub-specialist directly.

The Disclaimer

I am pleased to be writing a blog on women's health issues. I hope that by doing so I can help people by giving them the information they need from an expert in the field. Please keep in mind, though, that the information provided in this blog is not meant to be a medical opinion about your specific case. The problems of every patient are unique and should be addressed by their physician in a face-to-face conversation and thorough work-up. You are welcome to bring up questions about my postings with your doctor. However, no one should assume that this blog is a source of medical care. I believe that reading it might offer some insights into medicine that might not otherwise be available in the general media.

Welcome From Dr. Ramirez

Welcome to the first installment of the Women's Health and Fertility Blog. My name is Dr. Edward Ramirez and I am a gynecologist and infertility specialist practicing in Monterey, California (http://www.montereybayivf.com/). My goal for this blog is to educate women about their health and to help couples who face infertility. Over the past 13 years I have experienced the ups and downs that come along with a busy gynecology and infertility practice. Obviously, the ups have been great but the downs have made me realize that there is much still to be achieved in medicine to help women overcome their health problems. I hope to help people gain a better understanding of what is in the forefront in women's health and perhaps help them to seek better care for the problems they are currently facing. Thank you and please stay tuned!