Long Acting Birth Control Conundrum

[Katsmeow]

Very frustrated here. My daughter (who is on my insurance) was going to get Nexplanon which is a long acting form of birth control. This is implant that goes in the arm and lasts for up to 3 years.

The implant is expensive because it is releasing chemicals for 3 years (think about $1000). So, the gynecologist submitted the purchase of the Nexplanon as a pharmacy claim since they don't keep these in the office (since they are so expensive).

Pharmacy denies it. I'm surprised because I know ACA compliant policies must cover it. After lots of time on the phone with the insurer (United Healthcare) I find out that it is 100% covered as medical, not as pharmacy. Yay!

I call back the provider. The thing is they still won't do it. Here is the thing:

If they buy from pharmacy it is sent directly to them and they aren't out of pocket. If it is a medical call, it is treated like other medical claims. They have to buy the implant, insert it and then bill the insurer who will reimburse. They won't buy the implant since they have burned on that before and they don't get their money back if it never gets inserted.

So, yes, it is 100% covered but I haven't been able to find a way to actually get it. I called other doctor's office and they said they same thing. They won't do what is called "buy and bill." They said they didn't know of any doctors who would. Maybe I could find one but they seemed doubtful. I asked if I could give them money in advance to buy it and then have it get submitted to insurance. The answer was no. I could buy it in advance, but it would be pure self pay (except for the minor cost of the insertion).

I was told that Planned Parenthood actually keeps it in stock so she can go there. Great. The problem there is that Planned Parenthood is out of network so we will have a rather sizable 40% co pay.

I am just annoyed by this as it is a product covered by the medical plan and required to be covered under ACA. But, I can't seem to find a way to actually get it reimbursed since the providers I've talked to won't order it. I can have her do Planned Parenthood but there will be 40% co pay.

Anyway dealt with this? (Oh, and the same problem exists with IUDs but at a less expensive level).

 

[AllDone]

Call UHC and see how you go about getting her referred to PP as an in-network provider. UHC is perfectly capable of making that happen.

 

[AllDone]

Additionally, there may be some other family planning provider in your network besides PP. They keep a low profile for obvious reasons, but UHC should be able to tell you.

 

[Sarah in SC]

That seems crazy that they are making it so difficult. From their perspective, it should be promoted for the simple fact that a non-pregnant customer is way cheaper than a pregnant one!

Good luck with that. I really hope the insurance company can come up with a viable solution.

I've heard really good things about the new IUDs but don't know much about the implants.

 

[Katsmeow]

I've done some more research on this and it is a real problem. The commercial insurers now have to cover LARCs (long acting reversible contraception). Some cover the device as a pharmacy benefit, others as a medical. When covered as a medical benefit, the provider has to buy and bill the device (implant or IUD). They buy it, then bill the insurer after it is implanted and the insurer pays. The problem from the provider standpoint is that if for some reason the insured doesn't come back to have it implanted or losing insurance in the meantime the provider is on the hook for something costing several hundred dollars. So they don't want to do it.

Patients can't get reimbursed if they buy it. You buy it from a pharmacy and it isn't reimbursable under the medical policy. The only way the patient can get it covered is for the doctor's office to buy.

Places like Planned Parenthood have it in stock so it isn't an issue. The average gynecologist's office doesn't. The idea to try to find another family planning clinic that might be in network is a good one. I'm going to check that.

If that doesn't work, then it is probably cheapest to do it at Planned Parenthood where 60% of it would be covered. Of course, the other option is to just give up and have her get birth control pills which are 100% covered.

The problem with that is that the LARC methods are more effective and no problem of user error. While higher upfront cost, they last for years so the overall cost is not that different. But, I'm sure insurers would prefer people to use birth control pills. In DD's case, she takes medication that it would be really bad for her to have taken if she got pregnant so that is why the implant is preferred.

When it comes right down to it, we can pay the 40% at PP if we have to (while being annoyed that UHC is one of the few insurers where PP is not in network). But, it is so annoying when doctors keep telling me that they can do the implant (they have to be trained in it) and it is all 100% covered but it can't actually be done because they won't buy and bill.

 

[meierlde]

I've done some more research on this and it is a real problem. The commercial insurers now have to cover LARCs (long acting reversible contraception). Some cover the device as a pharmacy benefit, others as a medical. When covered as a medical benefit, the provider has to buy and bill the device (implant or IUD). They buy it, then bill the insurer after it is implanted and the insurer pays. The problem from the provider standpoint is that if for some reason the insured doesn't come back to have it implanted or losing insurance in the meantime the provider is on the hook for something costing several hundred dollars. So they don't want to do it.

Patients can't get reimbursed if they buy it. You buy it from a pharmacy and it isn't reimbursable under the medical policy. The only way the patient can get it covered is for the doctor's office to buy.

Places like Planned Parenthood have it in stock so it isn't an issue. The average gynecologist's office doesn't. The idea to try to find another family planning clinic that might be in network is a good one. I'm going to check that.

If that doesn't work, then it is probably cheapest to do it at Planned Parenthood where 60% of it would be covered. Of course, the other option is to just give up and have her get birth control pills which are 100% covered.

The problem with that is that the LARC methods are more effective and no problem of user error. While higher upfront cost, they last for years so the overall cost is not that different. But, I'm sure insurers would prefer people to use birth control pills. In DD's case, she takes medication that it would be really bad for her to have taken if she got pregnant so that is why the implant is preferred.

When it comes right down to it, we can pay the 40% at PP if we have to (while being annoyed that UHC is one of the few insurers where PP is not in network). But, it is so annoying when doctors keep telling me that they can do the implant (they have to be trained in it) and it is all 100% covered but it can't actually be done because they won't buy and bill.

What if you gave the Physician a deposit, so he could buy the drug, and then have the deposit return when the insurance pays. I.E. you take the financial risk off the physician.?

 

[NW-Bound]

What if you gave the Physician a deposit, so he could buy the drug, and then have the deposit return when the insurance pays. I.E. you take the financial risk off the physician.?

+1

I was about to suggest the same, but you beat me to it.

 

[youbet]

Patients can't get reimbursed if they buy it. You buy it from a pharmacy and it isn't reimbursable under the medical policy. The only way the patient can get it covered is for the doctor's office to buy.

it is all 100% covered but it can't actually be done because they won't buy and bill

Why make the doc's office buy and bill? There is indeed risk for them bringing in unique and non-returnable items when the patient may change her mind. Why wouldn't you pre-pay the doc for the implant? His office orders it (and is guaranteed not to be out a penny if your daughter never returns or whatever). After the procedure, doc's office bills insurance (under medical, not pharmacy) and reimburses you or leaves you with a credit on your account.

EDIT: Ooooops..... I see others have already mentioned this idea.

 

[6miths]

I've heard really good things about the new IUDs but don't know much about the implants.

+1

The new generation of progestin impregnated IUCD's have been game changers. Significantly lighter periods and less cramping while lasting up to 5 years. Cost is $300 in my neck of the woods.

 

[Katsmeow]

Why make the doc's office buy and bill? There is indeed risk for them bringing in unique and non-returnable items when the patient may change her mind. Why wouldn't you pre-pay the doc for the implant? His office orders it (and is guaranteed not to be out a penny if your daughter never returns or whatever). After the procedure, doc's office bills insurance (under medical, not pharmacy) and reimburses you or leaves you with a credit on your account.

EDIT: Ooooops..... I see others have already mentioned this idea.

Great idea. So good that I actually had that idea also. I've talked to two practices (including the one where I've been a patient for over 20 years) and no dice. They just don't want to buy it themselves at all even if they get paid from me first. I think these practices just have that policy. Makes no sense to me, but there it is. Maybe they just don't want to hassle with having to refund me later. I'm going to keep trying but it isn't looking promising so far.

 

[chris2008]

The deposit option was denied by the drs as mentioned in the first post already.

I asked if I could give them money in advance to buy it and then have it get submitted to insurance. The answer was no. I could buy it in advance, but it would be pure self pay (except for the minor cost of the insertion).

 

[AllDone]

Did you look specifically for a Family Planning practice rather than a general OB/Gyn practice?

 

[Theseus]

Great idea. So good that I actually had that idea also. I've talked to two practices (including the one where I've been a patient for over 20 years) and no dice. They just don't want to buy it themselves at all even if they get paid from me first. I think these practices just have that policy. Makes no sense to me, but there it is. Maybe they just don't want to hassle with having to refund me later. I'm going to keep trying but it isn't looking promising so far.

Could you imagine orthopedic surgeons refusing to to do knee or hip replacements because the patient might not return after ordering the implant? Cardiologist and pacemakers? There is nothing preventing the provider from doing this, it appears to be a matter of not desiring to do so based on their own concerns. Although the link is based on refusal to provide contraception (which I understand to not be the case) it would seem that requesting the provider to provide a referral to another provider who would agree to ordering the device might be an avenue to try.

Provider Refusal and Access to Reproductive Health Services: Approaching a New Balance

 

[Katsmeow]

Just to follow up on this. We ended up going with the PP option. I couldn't find any other place that had the implant in stock or would take a deposit. Since PP was out of network for our insurer (it is in network for many but not ours), I did have to put in up a deposit for the implant. When they get reimbursed by the insurer they will refund to us that amount. It is annoying that we will have to pay a 40% copay on something that would be covered in network 100%, but it was better than having to pay 100% of it.