At Reproductive Medicine and Surgery Center of Virginia, PLC, we want you to understand both the medical aspects of your care and the financial implications. Our staff has many years of experience in the fertility insurance field and is here to answer any questions you may have.
Coverage for this specialty is not easy to obtain and is not common in Virginia. Most commonly, coverage does include diagnostic testing (testing to determine why you are infertile), but not the treatment to help you become pregnant. Some medications may or may not be covered. Sometimes the insurance representatives do not give accurate benefits. We will help you to understand what benefits you have and make the process easier. RMSCVA does have a $50 no-show fee for any new patient appointments where patients did not come in nor reschedule their appointment.
Services We Perform for You as a Patient
We request that you provide your insurance card to our office prior to your appointment so that we may obtain your benefits. We will normally contact you prior to your initial visit to review the information that we obtained from your insurance company and you will be more informed about coverage for your first visit. At your initial visit, we will provide you with a copy of the benefits that we received. If at any time you feel you have different coverage, or a different level of benefit, please notify us and we can clarify the details. We also recommend for patients to call their insurance company directly as well.
Obtaining these benefits does not guarantee payment of services and insurance companies often will give a generic disclaimer. A common disclaimer would be “coverage is not determined until the claim is processed.” Coverage is based on several factors: if the service and reason (diagnosis) is covered by your plan; deductibles and copays have been met; and whether a pre-existing condition applies or not. In some cases, more complicated requirements for insurance coverage for services rendered include: you must be infertile for a specific length of time before coverage begins or the cause is not due to a previous tubal ligation or you must be married for a specific length of time. Some companies go as far as deciding which medical tests or treatments must be completed before coverage begins, which may not be the treatment plan our physician recommends for you.
Obtaining a referral (for managed care policies) for your initial visit is your responsibility. You also must ensure that you keep your referral up to date as insurance companies will not retro referrals. We will obtain follow up authorizations as your insurance company instructs us. Please be sure to always check out with one of the front desk coordinators to touch base regarding insurance needs as well as paying copays and other balances as required. This will help cut down on the number of denial letters and higher patient costs.
We will file all claims for you if we participate with your insurance company and if they inform us you have coverage for services rendered. We will collect all copays for office visits, deductibles and co-insurances for visits and surgery up front as well as the full amount if you have no fertility coverage under your policy or have exhausted your benefits. You will be billed for any balances your insurance company does not cover (and once we have exhausted all avenues for obtaining payment). The outpatient coinsurance’s that we collect are estimates only and based on actual charges to your insurance company as well as payments received from your insurance company.
If you are a satellite patient, your referring physician needs to send us a full benefit review so we know whether your services are covered or not as we will not bill your insurance company for non-covered services. They are also responsible for obtain authorizations when required.
If we do not participate with your insurance company, we expect payment in full at the time of your appointment. As a patient, we will provide you with the necessary information regarding services provided in order for you to file a claim directly to the insurance company for reimbursement. You must obtain the claim form from your insurance company.
Services rendered have to be paid at time of service if we do not participate with your insurance company or if you have exclusions to your plan. We will not bill you. Also, any balances on your account will be due at the time of your next visit.
There may be times when you have become a self pay or non-insurance coverage patient, but you come into the office with another non-fertility related complaint (i.e., pelvic pain, bleeding, etc.) or your diagnosis has changed for other reasons (a cyst found on ultrasound during a treatment cycle). If this is the case, we will bill your insurance plan for these services. However, if you come back to resume fertility therapy and your diagnosis has reverted back to infertility; the front desk will no longer bill the insurance company.
We want to help you overcome your fertility struggles with the least amount of stress possible, however we cannot code evaluation or treatment of infertility under alternative medical diagnosis codes as that is considered insurance fraud.
If you are being seen and/or evaluated by our physicians for non-infertility issues, such as polycystic ovarian syndrome, endometriosis, recurrent pregnancy loss (prior to any medication treatment) or other reproductive health concerns, your diagnosis codes will reflect this.