Ob-Gyn Coding Alert

Dr. Niels H. Lauersen, the high-profile Manhattan obstetrician on trial for insurance fraud, was recently found guilty and faces up to 20 years in prison. The conviction is a warning to ob/gyns of the consequences of fraud and could set off more legal battles over insurance companies refusal to cover fertility treatments.

Ob-Gyn Coding Alert first reported on Lauersens case in March 2000 in a story on the challenges of obtaining reimbursement for fertility treatments (see Overcome Challenges to Receive Appropriate Reimbursement for Infertility Treatments, page 17 of Ob-Gyn Coding Alert, March 2000). Lauersen was accused and ultimately found guilty of submitting false claims to insurance companies so his patients expensive fertility treatments would be paid for. For example, Lauersen would bill a patients carrier for a covered benefit like ovarian cyst removal (58925) when he was in fact conducting in-vitro fertilization, an expensive and non-covered benefit.

Champions of Lauersen, including many couples who were able to conceive and have children through his efforts, herald him as a hero fighting against an insurance industry that for the most part refuses to pay for fertility treatments. Critics assail him for defrauding insurance companies of millions of dollars over the years.

As more and more women turn to expensive fertility procedures, Lauersens verdict sheds light on the lack of insurance coverage for these treatments. Although several states have laws mandating that fertility care be a covered insurance benefit, most of the laws are so replete with loopholes as to be unenforceable. In New York, where Lauersen practiced, insurers must pay for all problem-oriented ob/gyn care. But since infertility is not considered a medical problem or condition, treatment to correct it is not a covered benefit.

The case is expected to impact future insurance fraud cases on similar grounds and could potentially impact insurance company policy. And while the Lauersen case appears to be a legal coup for insurance companies, it is certainly not the last legal challenge the industry will face, as more and more women are suing their insurers to demand coverage of fertility treatments.