Doctor Billing for Medication/Supplies - how to file with insurance

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My wife has been doing IVF treatments. This is covered by my insurance so most everything has been paid. The only issue we had was egg freezing where the doctor told us $750, our expense, but neglected to reveal another $400 charge. Aetna is our health insurance provider and CVS Caremark is the prescription drug provider.

My question though has to do with the doctor billing for Medication / Supplies when our first attempt became an ectopic pregnancy (which is independent of IVF). She had a lot of pain the night before, we considered going to the ER, but instead, raced to the doctor's office first thing the next morning. I drove her. Doctor concluded there was a problem, and asked the nurse to give her 2 shots of  methotrexate. 

I saw that Aetna covered the visit. A bit higher than other visits, but we've exhausted our out-of-pocket coinsurance, so it is all paid 100%. Then the doctor gives us a bill for $50 for Medication / Suppliers. How do I handle this?

In the past for OB/GYN issues, this has been quite confusing. Aetna often won't pay because it is medicine. CVS Caremark won't pay because they claim you have to get it mail-order, but for situations like this, there is no time. Does anyone have any tips?

For the 2nd shot that she needed, we were on vacation and just went to an Emergency Room. For Emergency Rooms, luckily, the drug is covered. I haven't seen the visit yet on Aetna's site, but I presume it will be covered 100%. My question is for the first shot, where the doctor is now charging $50 for their pharmacy expense for the  methotrexate. Any help would be appreciated.

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I assume you do not have prescription coverage. In this case, I doubt that this would be covered, since medicines given out by the doctor's office won't be covered, just like any script he would give you.

Medicines given during an ER visit are another story, as those given are part of the ER visit and treatment.

Not a doctor, pharmacist, or insurance agent. Nor play one on TV.

We have both prescription coverage, through CVS Caremark, and health insurance coverage, through Aetna.

Have you called your insurance company to ask them if they would cover the shot the doctor billed you for, and if they won't, to explain to you why not? You can also appeal a denial-of-payment decision, if you want to.

Have you asked the doctor's office to submit that bill to the insurance company (even if the final result will be that the insurance company says they won't pay it, you will still want the expense to be recorded by them in your out-of-pocket charge totals, and sometimes the insurance company will have a discounted rate that they will tell the doctor to charge you, if the doctor has charged you the full, no-insurance-involved rate. I have my insurance company to process every medical charge, and I don't pay a medical bill until I see a confirmation of the amount I owe on the insurance company's explanation of benefits mailing.)

Since it was only $50, it couldn't be handled by your mail-order prescription service, and it was necessary, I would say just pay it.

(If a pregnant woman is in a lot of pain, surely most people would go to an emergency room immediately and not wait until the next morning, especially if the pregnancy is planned and was arranged by having IVF - ?)

(I thought I saw a question here a few weeks ago about being charged more out-of-pocket by a doctor for IVF than the poster had expected, something about regretting that they didn't take part in a free research study, but I don't see it anymore.)

Thanks everyone for the input. I found out why. Aetna considers methotrexate for the treatment of ectopic pregnancy to be experimental, and doesn't cover it. Even though ectopic pregnancy is an emergency and the only other alternative is surgery. When my wife had an ectopic pregnancy a year ago and was seen in an emergency room, Aetna denied the methotrexate charge of $41 and the emergency room ate the cost.

That explains why the doctor billed us, and why the bill for it is so vague. They know it will be denied. And their bill is only $50. Had we gone out to a pharmacy to buy it on ur own and bring it back to the doctor to give by injection, the copay would have been $50.

So that's it.

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