The $3200 Baby… and why Oxford Insurance Sucks!

I know, two posts in one day.. but I’m totally fuming (sorry blobby, hopefully my heart rate will go back down to normal in a few minutes!) after I just got off the phone with Oxford.

Let me preface this by saying I am completely grateful that I have any infertility insurance coverage at all and I know I am one of the lucky ones.


So my current plan is through Oxford, which covers ART (assisted reproductive technology) up to $5k per calendar year. Because I anticipated having to do IVF, when open enrollment came around for 2008 I decided to switch to our Aetna HMO plan because it covered up to three full cycles of IVF.

As a separate prescription pharmacy benefit plan we also have $15k lifetime coverage for infertility medicines.

That may seem like a lot (and it is compared to many plans) it probably covers about 3 cycles worth of IVF meds.

So, when it came time to decide how to pay for my Gonal-F injections that I started while still with my oxford plan in November I had the choice of using up part of my $15K under my prescription plan, or, I could run it under my Oxford medical plan which covers certain types of ovulation induction medications.

It seemed like a no brainer. I’m getting rid of Oxford anyway, so might as well have them pay for the meds so that my $15k is intact for when I needed IVF. The only catch was that Oxford said they would cover it, but I would have to put out the money first and they would “reimburse me” when I submitted a claim for it.

I did some quick calculations and realized that I could put it on a credit card and within the 20-30 days Oxford said it customarily pays out its claims in, I should have the check in hand and be able to pay off my credit card without accruing any interest fees. Besides, when I looked at the price list for meds at Freedom Fertility Pharmacy I calculated the whole thing should only cost me about $1100 – or so I thought.

Turns out those prices listed are for self-pay clients with no fertility drug coverage, the prices TRIPLE if they are going to be run through an insurance plan. So my combined total for the Gonal-F, Ovidrel and Endometrin combo was $3200!


Oh well, I’ll still have the check from Oxford in hand by the time I need to pay my credit card bill. Right? Right?


About two weeks after I submitted all my paperwork to oxford I am logged into their system looking at my various claims and see the one for the $3200. It says it was denied. I IMMEDIATELY call up and talk to a claims representative who assures me that it its still in review, that he doesn’t know and can’t see the system that I am looking at but that it has definitely not been denied.

Not being one to trust what one person tells me, I call back a few days later just to “double check”. I speak to a young woman who cheerily informs me that yes, it has in fact been denied.

“What?” I screech, “Why?”

She tells me that it was denied because I had no preauthorization.

“But I have preauthorization” I tell her.

“Yes I see that” She says. “I’ll have to resubmit it, I don’t know why they denied it.”

You can see where this is going. GRRRRR.

So I wait another week and call back again. The man who answers the phone tells me its still under review, and could be for another few weeks.

Now I’m starting to panic because my credit card statement is due quite soon.

So I wait about another week and call back today. Claims rep Melissa E. tells me its been denied, this time because its not a “covered” benefit.

Uh, then why did you tell me that it was, and my RE’s office when THEY called, and why the hell did you preauthorize it if its not going to be covered anyway? After being on hold to “research” my plan’s benefit for about 15 minutes she tells me that she talked to a supervisor and that infertility meds ARE covered under our medical plan if they are part of ovulation induction and “Comprehensive” care which means artificial insemination, sperm washing etc. etc. Basically everything that we/I did. Does she think I was injecting myself with Gonal-F for FUN???

It just makes me so mad..

First the shady “pay for it first and we’ll reimburse you later” deal, its almost like you KNOW they are just banking on being able to deny some of those claims, or make it so difficult that people just give up. And then there’s the fact that it’s completely wrong to keep wrongfully denying a claim that is costing the patient a big chunk of change each month. I feel like they are willfully trying to hold on to the money as long as possible.

The credit card interest for $3200 is not peanuts.

Now of course I would gladly pay $3200 to have my baby and a hell of a lot more if I had to. In the scheme of things its really nothing, its just that the unfairness and the wrongness in principle really gets my libra goat and makes my blood boil.

So I say BOO to Oxford and their complete lack of competence. I really have enough stress already in my life worrying whether or not my baby will have a heartbeat or not next week.. I can only think how much more incensed I’d be if that $3200 DIDN’T result in our beautiful little blobby.. thank GOD is all I can say to that.

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iloveupstate says:

Write a short letter to Oxford outlining the problem and time line (I find that bullet points work best since short attention spans are rampant) and cc: the CEO of Oxford (google…) as well as the PR person (google it…) and also the editor of a few choice publications (Parents Magazine, Good Housekeeping, Reader’s Digest) and lastly…Cuomo’s office (he’s our current Attorney General).

Yes, I play hardball when I know I’m getting screwed over.

Good Luck!!

Holly says:

I highly reccomend you write a complaint to the insurance comissioner for your state. You may see some “action” from the insurance company then.
Insurance companies bank on folks not fighting a denied claim. Best of luck!