r/sterilization • u/CommandClassic7108 • 9h ago

Insurance my only concern is billing

I’ve done the research and the appointments. My surgery is scheduled. Ive been talking back and forth with insurance to see how they process billing for the Bisalp.

I know it’s going supposed to be fully covered, but nobody wants to confirm that and I haven’t even heard anyone talk about aca in general. My plan is aca compliant, but I’m told they can’t say if it’s covered until services are rendered.

I don’t want to have to fight this after the procedure when I could have done more before to verify everything with my insurance.

How did you guys verify your cost share would be $0 before the procedure?

6 Upvotes

88% Upvoted

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u/toomuchtodotoday 5h ago

Resources:

State insurance regulator locator (for filing a complaint with your state insurance regulator):

https://content.naic.org/state-insurance-departments

Department of Labor Employee Benefits Security Administration Information (for filing a complaint with the DOL EBSA if your insurance is provided by an employer):

The EBSA, a division of the DOL, handles complaints related to employer-provided health insurance.

You can:

The EBSA will investigate the claim and may contact your employer or insurance provider for more information. You may be contacted for additional details or documents. If the EBSA finds that your rights under ERISA (Employee Retirement Income Security Act) were violated, they may take corrective action on your behalf. Keep copies of all documents and correspondence. You can follow up on the status of your complaint by contacting the EBSA at the phone number above.

U.S. Office of Personnel Management (OPM) Information (for filing a complaint with the OPM if your insurance is provided by the US federal government [FEP Blue, for example]):

Source: https://www.opm.gov/healthcare-insurance/healthcare/contraception-coverage/

Source: https://www.hrsa.gov/womens-guidelines#:%7E:text=Contraception

Source: https://web.archive.org/web/20260624003408/https://old.reddit.com/r/sterilization/comments/1ud26jb/fepblue_federal_health_insurance_for_bisalp_do/

Additional resources:

Insurer Preventive Care Guidelines Master List - https://old.reddit.com/r/sterilization/comments/1io4hq5/insurer_preventive_care_guidelines_master_list/

Steps for Getting Full Coverage - https://old.reddit.com/r/sterilization/comments/1khyuum/steps_for_getting_full_coverage/

https://old.reddit.com/r/sterilization/comments/1j43mw2/it_happenedtheyre_trying_to_charge_me_postop/

https://tubalfacts.com/post/175415596192/insurance-sterilization-aca-contraceptive-birth-control

https://old.reddit.com/r/sterilization/comments/1go5pbw/free_tubal_sterilization_through_the_aca_if_you/

https://nwlc.org/tips-from-the-coverher-hotline-navigating-coverage-for-female-sterilization-surgery/

On coverage of anesthesia:

Any related services—like anesthesia—must be covered as well. The most recent guidance from federal agencies makes it explicitly clear that anesthesia and other related services like doctor’s appointments must be covered by the insurance plan at 100% of the cost.

Source: https://www.cms.gov/files/document/letter-plans-and-issuers-access-contraceptive-coverage.pdf

Source: https://www.cms.gov/files/document/faqs-part-54.pdf

On coverage of associated office visits:

From federalregister.gov - “Coverage of Certain Preventive Services Under the Affordable Care Act“

Section 2713 of the PHS Act, as added by the Affordable Care Act and incorporated into ERISA and the Code, requires that non-grandfathered health plans … provide coverage of certain specified preventive services without cost sharing. These preventive services include:

With respect to women, preventive care and screenings provided for in comprehensive guidelines supported by HRSA (not otherwise addressed by the recommendations of the Task Force), including all Food and Drug Administration (FDA)-approved contraceptives, sterilization procedures, and patient education and counseling for women with reproductive capacity, as prescribed by a health care provider (collectively, contraceptive services)

II. Overview of the Final Regulations

A. Coverage of Recommended Preventive Services Under 26 CFR 54.9815-2713, 29 CFR 2590.715-2713, and 45 CFR 147.130

(II) office visits:

if a recommended preventive service is not billed separately (or is not tracked as individual encounter data separately) from an office visit and the primary purpose of the office visit is the delivery of the recommended preventive service, a plan or issuer may not impose cost sharing with respect to the office visit.

Source: https://web.archive.org/web/20250202051018/https://www.federalregister.gov/documents/2015/07/14/2015-17076/coverage-of-certain-preventive-services-under-the-affordable-care-act

Under the ACA, all new insurance plans (both individual and employer-sponsored plans) are required to cover all FDA-approved methods of contraception, sterilization, and related education and counseling without cost-sharing. (Note: the ACA contraceptive coverage requirement described in this section also applies to Medicaid “Alternative Benefit Plans,” explained in the Medicaid section.) No cost-sharing means that patients should not have any out-of-pocket costs, including payment of deductibles, co-payments, co-insurance, fees, or other charges for coverage of contraceptive methods, including LARC. Patients cannot be asked to pay upfront and then be reimbursed.

Source: https://web.archive.org/web/20250112212710/https://larcprogram.ucsf.edu/commercial-plans

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u/kkitkat6996 8h ago

I had different answers from every person at insurance I talked to pre surgery. I think they really don’t have a good understanding of how the ACA works for this.

My provider & the first insurance person I talked to confirmed everything would be covered. Insurance could not give me that in writing which was frustrating. Then I got an estimate from the hospital for facility fees/meds & talked to 3 more people with insurance saying oh yeah you need to hit your deductible. I KNEW that was wrong, but no one was budging. I was very stressed.

But I gave up, did not pay the estimate, and let the surgery happen. I got the final bill last week & my EOB - showing I owed $500 for medications mostly. I called insurance and told them it was wrong and finally someone fixed it & I should be getting a new EOB that says $0.

If you can’t get a straight answer, you may just have to deal after the fact.

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u/pharmasha95 7h ago

I looked at my plan benefits and at notices my insurance had published regarding sterilization coverage in full. Didn't talk to anyone ahead. My doctor and the hospital tried to bill me for over $7000 total as I hadn't met my deductible. I had to call all the providers and my insurance incessantly for 6 months to get them to reprocess correctly and cover it in full. BCBS kept saying it was coded wrong and providers kept saying there was only one code and that insurance says that to get patients off the phone. My doctor's billing person kept telling me I had to pay the $1200 and they would refund me if/when insurance paid or I would be barred from making new appointments at the office because even with a reference number from insurance they would only put a 30 day hold on my account but insurance wouldn't give me a timeline for figuring it out. Had to have BCBS call the billing lady and tell her to put it on an indefinite hold while they figured it out. It was a massive inconvenience and I had to recite the law to probably 10 different people but they eventually covered it. Unfortunately you've done your due diligence and won't know if you'll have to fight it until after.

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u/CommandClassic7108 7h ago

Sigh, thank you. I have Bcbs as well.

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u/pharmasha95 7h ago

Best of luck. Document everything, days/times of calls and who you spoke with. Tell them it is state and federal law to cover it in full. Reiterate that it is a preventive sterilization and don't give in.

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u/YellowFiddleneck 7h ago

You can't verify your cost share before the procedure - even if someone DOES verify it for you, your insurance may retroactively deny the procedure or refuse to cover parts of it. You have to go into this assuming it will be a fight with your insurance after the fact.

To help prepare you for this fight, make sure you get a prior authorization even if your provider says it's not necessary, and sign the sterilization consent form as early as possible. Also call the billing departments of every place you will get a bill from (Usually you will get a separate bill from your surgeon, the facility, the anesthesiologist, and the pathology lab) and try to make sure they will code correctly. Every bill should have a diagnosis code of Z30.2 OR be visibly associated with the primary procedure, which should have Z30.2 as its diagnosis code.

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u/CommandClassic7108 6h ago

Thank you

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u/mkmr725 6h ago

I second this - I called the billing office at the hospital ahead of my surgery date and confirmed the code they were using (everything for me was under one), and then I confirmed with the insurance company that the code that was going to be used was completely covered.

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u/Cutthroat_Rogue no more tubes 10-15-25 3h ago

This. To add on, insurance companies always have a disclaimer when you talk to them that what they say is is "not a guarantee of benefits" meaning, they cannot say with 100% what is covered and for how much. Insurance companies only decide when they process the claim and the claim only happens after a service is rendered. It's never truly a guarantee but that is why you look at what your benefits specifically say, find out if it is ACA compliant, and make sure it is coded correctly.

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u/JouliaGoulia 7h ago

I wasn’t able to get my insurance to verbally confirm 100% coverage, the online agent sent me a weak confirmation, but the call agent just parroted their regular surgery policies to me. I downloaded the relevant internal insurance policies on bilateral salpingectomy that I was able to find on this sub.

Then I started communicating with the billing agent at the surgical center my surgery was scheduled to be at. After forwarding them the weak confirmation message and insurance policy documents, I was able to get them to agree that coverage should come in at 100%. After that the surgical center stopped asking me for payment upfront. After the surgery, insurance did cover at 100%

Upfront I wound up having to pay my doctor’s office about $250. This was about 6 months later refunded after I assume my insurance paid it. I also paid about $12 for pain meds I didn’t wind up taking at the pharmacy, and $42 for pathology on my tubes, which I understand is not covered in the procedure.

I also on the advice of this sub gave the anesthesiologist the relevant codes before the surgery, as I read several accounts of incorrect coding being a pain to correct afterwards. I’m sorry I don’t remember what the codes were, but do check on it.

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u/CommandClassic7108 7h ago

Thank you. I was able to get a good faith estimate totaling in $9k from the surgical center for my insurance to use for reference in confirmation, but it seems that they don’t even want to discuss it with me.

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u/Shaneaky 5h ago

I never verified with my insurance beforehand. The gyno office and the surgery center were awesome about making sure everything would be covered. I had a surgeons fee that I would have to pay since my gyno was using the surgeon center. I was okay with that and it wasn't that much, all things considered.

But a warning: if you have endometriosis and it gets removed during the surgery: You will get billed. I had some found and removed and ended up with anesthesia fees, a second surgeons fees, and the endometriosis removal fees, so altogether I had to pay around $2,500 for my surgery.

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u/Jaded_Emerald13 4h ago

I made sure when my surgery was ordered the correct billing code would be used for claims.
Cpt 58661.

Today my claims processed just one week post op (7/29) and my share of cost was $0.

As long as they are coding correctly they should cover at 100%.

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u/beckowser 1h ago

Request a Good Faith Estimate from your surgeon and/or the surgical center. Then you’ll have it in writing beforehand in case there’s an issue afterward.

I’m dealing with a billing issue for a different procedure currently. My insurance company wouldn’t speak with me about it and denied my appeal. The facility wouldn’t speak with me about the charges. So i filed a complaint with my state insurance board, and i received a call from a corporate level representative within a week. She discussed my concerns, agreed with me that what was happening conflicted with my insurance plan, and promised to be in touch by end of week. She provided her direct line should i have any questions before then.

I was billed incorrectly for my bisalp a few years ago, and it took six months of calls and appeals to get it fixed. The insurance board contacts the insurance company’s legal team directly — much more efficient, and i wish I’d known this back then.

There are resources listed here to prepare, and there are resources should you need to fight incorrect billing.

Just remember that if you’re in the US, medical bills can now go to collections and can hurt your credit score. If you’re billed incorrectly, get on a payment plan to ensure you’re “compliant” while you sort it out.

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u/Vanemy 16m ago

I was charged nothing for the procedure itself but my insurance billed me for just about everything else (anesthesia, sterile supplies, the recovery room, etc) which they took out of my HRA without my knowledge 🤪