Even when IVF is covered, high bills and hassle abound: pictures

Oona Tempest/Kaiser Health News

A woman with a medical bill

Oona Tempest/Kaiser Health News

After years of unsuccessfully trying for a baby, Brenna Kaminski and her husband Joshua Pritt decided to try IVF.

Only 15 states require insurance to cover infertility treatment, and Florida, where Kaminski and Pritt live, is not one of them. Yet the couple’s insurance, from Preet’s job at an energy company, did — putting them among the lucky minority of Americans whose insurance plan covers the expensive fertility procedure. Kaminski and Pritt worked out what their share of the cost would be for one IVF round: $2,700, the out-of-pocket maximum under their policy.

Instead, after many twists and turns with two specialty practices, they paid more than $15,000 for two rounds of IVF, including all medications. And as is true of the majority of national procedures (success rates range from 12% to 49% depending on the patient’s age), not a single round resulted in a viable pregnancy. “This whole thing has been a nightmare,” said Kaminski, 37, who does freelance marketing and writing. “The stress was incredible.”

Around 1 in 5 women have trouble getting pregnant and IVF has become a common route to parenthood for many. But even as demand grows, insurance coverage remains limited. About 27 percent of companies with 500 or more employees covered IVF in 2020, up from about 24 percent in 2015, according to Mercer, a consulting firm.

“Infertility is a disease and should be treated as such, and insurance coverage should reflect that,” said Dr. Cara Goldman, associate professor of obstetrics and gynecology at Northwestern University. “Coverage is often incomplete because people too often don’t see infertility as equal to other illnesses.”

Kaminski’s insurer, Blue Cross and Blue Shield of Illinois, offered a list of IVF providers in the network near the couple’s home in Melbourne, Florida. For in-network care, the couple will be responsible for 20% of the cost. For out-of-network care, they will have to pay 40%.

The first network specialists to try in the spring of 2020 had an office nearby, in Viera, Florida. But after seeing the doctor, they learned they had to travel 3½ hours to Miami, where the doctor performed the IVF procedures in three separate visits.

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The couple paid about $2,700 out of pocket for the drugs alone. They also paid an extra $500 because the fertility clinic required them to use an out-of-network lab for blood tests.

In November 2020, the couple decided to try again with another fertility medical group included in their Blue Cross provider network. It was in Winter Park, Florida, about an hour’s drive from their home.

Kaminski saw doctors at the Center for Reproductive Medicine, and they scheduled her to begin the procedure at their facility in the same building. But that facility, Orlando Avenue Surgery Center, was not in the Blue Cross network.

Kaminski said the surgery center told her it was likely to be added to the Blue Cross network soon, and she reached out to the insurer for a waiver to have the center’s care considered in-network. The insurer’s customer service agents told her she would receive the waiver, but she received no written confirmation. Still, she went through with the procedure.

That happened in 2021, and Kaminski again expected to pay about $2,700 out of pocket for the IVF specialist’s care in Winter Park. She knew she would face separate out-of-pocket costs for the drugs used in IVF.

But because her care was deemed out-of-network by Blue Cross, Kaminski said she was billed more than $6,000 by the clinic and its surgery center. That was in addition to nearly $4,000 in out-of-pocket drug costs.

Kaminski spent nearly a year trying to get Blue Cross to treat her second round of IVF as in-network. She said it was unfair for Blue Cross to include the Winter Park Fertility Clinic in its network of providers if its doctors performed the actual IVF procedure at an out-of-network surgery center. The surgery center is owned by some of the clinic’s doctors.

In a statement to KHN, the Center for Reproductive Medicine’s executive director, Stephen Brown, did not want to address Kaminski’s case specifically, although she has given him permission to discuss it. In an email, Brown wrote that the clinic is transparent with all of its patients that its surgery center is not in the Blue Cross network.

Brown said low recovery rates aren’t what’s keeping the surgery center out of the Blue Cross network. Instead, he said, the insurer didn’t act quickly and it took more than four years to add the surgery center to its network of providers. “The reason we were initially out of network with BCBS was solely based on the lack of response from BCBS,” Brown said.

Before any treatment is performed, Brown said, the clinic gives its patients cost estimates for their procedures based on their insurance. Kaminski was given an estimate where she could expect to pay $3,000 to $4,000 just to transfer the lab-grown embryos into her uterus.

In March 2021 — about a month after Kaminski completed his treatment — Winter Park Surgery Center was added to the Blue Cross provider network.

In February 2022, KHN contacted the supplier and the insurer. Within two weeks, Blue Cross told the couple it would consider all services they received at the in-network surgery center and paid all their bills in full. Kaminsky and Pritt no longer owed the center anything. Blue Cross initially said it would pay a nominal portion of the disputed bills, which totaled $21,450 for care in 2020 and 2021, because the surgery center was out of network.

Blue Cross also confirmed to the couple that in January 2021 it granted them a waiver so that all of the surgery center’s bills could be considered in-network. By mistake, the exemption was not applied, so they face the high out-of-network charges.

“It finally makes logical sense,” Preet said after learning their billing dispute had been resolved. “It’s good to know we won’t be getting any more bills.”

After Blue Cross decided to cover IVF in Winter Park, the couple received a $1,600 refund from Orlando Avenue Surgery Center.

John Simley, a spokesman for Blue Cross and Blue Shield of Illinois, said, “With non-routine denials, mistakes can happen. The good news is that they usually get better quickly.”

In this case, however, it took nearly a year.

Experts say Kaminski’s case shows that even when people have IVF coverage, they can be left with huge bills. In addition, insurers’ lists of in-network providers are not always accurate. “It feels like a bait and switch,” said Sabrina Corlett, research professor and co-director of the Center for Health Insurance Reform at Georgetown University.

A new federal insurance law, the No Surprises Act, went into effect in January 2022. It says patients don’t have to pay more than the in-network cost-sharing amount if an insurer’s provider directory gives inaccurate information.

It is unclear whether the law will apply in cases like Kaminski and Pritt. Even if it did, the law came into force too late for them.

Betsy Campbell, chief engagement officer at Resolve: The National Infertility Association, a patient advocacy organization, said Kaminski’s case shows that insurance coverage isn’t always designed around the patient. “Infertility treatment is a series of very complex procedures involving lab work, surgery, anesthesia, and has to be covered in a way that the insurance system hasn’t always followed,” she said.

Too often, insurance makes the couple jump through hoops to get the care they need, Campbell said. “Everyone should have the right to raise a family, and it shouldn’t matter what employer you work for, what state you live in or how big a check you can write,” Campbell said.

Kaminski and Pritt are not giving up on having children. For now, they are pursuing other non-IVF infertility treatments.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism on health issues. It is an editorially independent operating program of the KFF (Kaiser Family Foundation).

Bill of the Month is a crowdsourced investigation by KHN and NPR which analyzes and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!

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