Ob-Gyn Coding Alert

A recent high-profile legal case in New York City has reproductive endocrinologistsas well as other medical practitionersstanding at the sidelines awaiting the outcome. The Feb. 7, 2000, issue of Time magazine reports on charges pending against New York gynecologist Niels Lauersen, who is accused of defrauding insurance companies out of millions of dollars. Lauersen allegedly submitted false claims to the insurance companies because the actual infertility procedures he was performing were not covered by his patients insurance. So a treatment for in vitro fertilization might be reported as the removal of an ovarian cyst, etc. The insurance companies claim that Lauersen bilked them out of as much as $4 million. Defenders of Lauersen claim that if he did fudge the records, it was to help his patients, many of whom could not afford the costly treatments and, subsequently, would never have gotten pregnant and had children.

The case brings to light a major problem for all gynecologists working with infertility treatments and in vitro fertilizationthe fact that most insurance companies simply do not pay for infertility treatments. As Susan Callaway Stradley, CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C., puts it, There are a lot of battles that are currently being fought in this arena, with the Lauersen case being the most high-profile one to date. With reproductive endocrinologists only just now beginning to get paid by insurance companies, its going to be an uphill climb for some years to come.

With so many insurance companies not covering even a portion of infertility treatments, practices often are requiring their patients to pay for the treatments in advance. In the rare instance where the insurer covers all or part of the procedure, a refund then is made to the patient.

Perhaps the most difficult aspect of insurance denials for infertility treatment is the emotional stress of patients who want to get pregnant but are unable to afford the procedures that could help them.

Lack of Understanding Is the First Stumbling Block

Callaway-Stradley explains that a big part of the problem with infertility treatments of all kinds is that insurance companies generally dont understand the steps involved in a process like in vitro fertilization. She visited Lauersens offices last year as a consultant, where she was shown around the fertility lab, and the extremely involved processes were outlined to her. Most people dont understand what is involved, she says. I certainly didnt before I visited.

Valerie Reno, billing representative for The Fertility and Reproductive Health Center, a group of fertility specialists in Annandale, Va., echoes Callaway-Stradleys contention that insurance companies dont realize what procedures are required for fertilization treatments. We have a few insurance companies who [...]