Nick Stretchbery, Manager of Business Intelligence, opened up with Reddit in a no-holds-barred question and answer session. Nick, who is also an FCI patient, has a unique position within the infertility community.

Redditor: 

We were fortunate that my husband’s company purchased an infertility rider for 2018, and we have been able to proceed with IVF. I recently discovered that my husband and I actually have individual infertility limits of $15k each, and IVF has been billed against my limit so far. I’m hopeful that we won’t need much more treatment this year, but in case we do, is there a way to take advantage of my husband’s infertility coverage once my limit runs out? Will insurance ever accept billing against a male’s limit for IVF?

Nick:

That’s great that they cover! Most aren’t quite as lucky. Generally speaking, insurance really only covers the patient. But that depends on the insurer. Talk to your clinic and ask them to do some insurance benefit verifications with both you and your husband’s policies. They’ll be able to tell you after that. Your husband’s treatment would most likely get covered on his insurance, though.

Another option: see if you can’t get on your husband’s insurance next benefit year. The cost might outweigh the cost of IVF, but you never know.

Redditor:

Hi! I’m actually an FCI patient and I’ve been super impressed with the quality of care (and I have a lot to compare it to after a previous clinic and many rounds of IVF).

My question is about making data more available to patients. I’m a data scientist and it’s always puzzled me how all IVF results and updates are conveyed over the phone (I’ve seen this across clinics and care givers as well). I’d love to see that data end up in the portal or somewhere I can actually see it. Is this a demand you guys are seeing from patients or via industry trends? How can we make this happen?

Nick:

Glad you’re having a great experience! Our teams work super hard :)

We actually just launched a patient portal (https://fcionline.com/patient-portal/) that patients can log into. It has things like a messaging section, your treatment calendar, financial information, and results! So sign up and talk to your clinic nurse – they’ll start publishing your results as they come in.

I think previously, test results were seen as a very sensitive thing. Plus, people tend to have questions about why a particular value might be off or different than expected and dwell on it, even if it has minimal impact on treatment. But we’re starting to see patients take a proactive approach to their treatment.

Redditor:

Also a patient and echoing the previous comment, I found that I have to ask for the test results to be posted to the portal every time, and they don’t always end up there (sometimes I get them in emails).

Nick:

It’s still a brand new process for us, so we’re still learning. Many patients are still accustomed to the phone call, so that’s the default so we don’t catch anyone off guard with sensitive information.

But, if you’re consistently not seeing results in the portal, send your nurse an email and let them know you’d like to use the portal more. I have to do the same occasionally, oddly enough.

Redditor:

Do you have any thoughts on why infertility treatment is so expensive for the many of us with no coverage and why it’s not considered “medically necessary”? Obviously you are aware of the restrictions and frustrations of fertility treatments from your personal experiences with the process, but do you feel like others on your end understand how difficult a process this is emotionally and financially?

Nick:

Short and sweet: I think it’s insanity that it’s not medically necessary. Fertility treatment is so frustrating as a patient, even as someone who is an “insider” who knows the process. There are definitely resources available for out of pocket patients: grants, cash discounts, insurance discounts programs for medicine, and refund plans. But I agree, there should be more done in the greater medical and insurance world.

As for understanding of the difficulty of the process from the clinic side: we wouldn’t be in this if we didn’t understand and want to help. It’s too hard otherwise. And I can tell you that there are more than a handful of my coworkers who have gone through treatment and it brought them to FCI.

Edit: wanted to throw in some resources: https://fcionline.com/financial-guidance/payment-programs/

Redditor:

Were you and your wife patients before you started working at the clinic? What’s it like to receive such critical/life-changing/fragile care at your own employer’s office?

I’m intrigued about the analytics side of things. Are you optimizing a patient’s plan of care based on lab results, age, insurance, etc? So if I showed up with x, y, z, you’d show that the most successful course of action is to do a, b, c? Or are you optimizing the way to store/ handle the mass quantities of data you collect?

Nick:

It is … interesting! There’s patient Nick and employee Nick. The two don’t ever intersect unless I want them to and everyone is super professional and respects our privacy. Plus, I literally trust my coworkers with my family. I started here the week before our consultation and it was highly coincidental – saw the job posted as I was researching the clinic to be a patient. Happy accident!

I am not in that part of it – our clinical team goes over each patient chart individually. Where we come in is working on processes to make sure check in time isn’t too long or looking at number of patients versus number of nurses on staff. That sort of thing reflects on patient care, but not necessarily on patient treatment, if that makes sense!

Redditor:

My husband and I are on the same plan under his employer. We’re lucky to have some decent coverage, and we each have a lifetime max. We were told by our clinic’s billing department that they would bill sperm wash, insemination and embryo culture under my husbands name to use some of his benefit. However, they billed it all under mine. Do you know if this varies across plans and insurance companies? Perhaps mine is one that only allows billing under the patient receiving the embryo and the clinic’s billing staff was incorrect. Thanks for doing this AMA!

Nick:

Of course! Happy to be here :)

The sperm wash, insemination, and culture are always under the patient who is receiving the treatment. So unfortunately, that’s you. The only things that they’d be able to bill your husband are things where he’s directly the patient, like exams, aspiration, semen analysis, and similar.

Redditor:

Being that your in Illinois and there is a Naval hub there, have you ever dealt with Tricare? That hardest part about the journey we are about to take is that our insurance is a little unique since my husband is military and we use on base facilities and we are thankfully in one of the areas that does IVF. so I was curious if you’ve ever worked with Tricare insurance.

Nick:

We definitely work with Tricare! We try to make the process as easy as possible, so give our office a call and they’ll go over all of your benefits in detail. We’ve heard people say that the Tricare website is tough to navigate, so we put together some resources to look at for just that reason: https://fcionline.com/financial-guidance/payment-programs/building-military-families/

Redditor:

So basically I have low AMH 28 years old with the eggs of a 40 year old. My level dropped from 2.4 to a 1 in just a year and with that most probably have poor quality eggs (had 2 losses). So my insurance wants 3 Failed IUIs before IVF. I have a huge concern of getting pregnant with the IUI and it being with a poor quality egg and I have to go through more losses which means more wasted time and my levels could drop even more. Another issue is if I’m pregnant with a healthy pregnancy then my chance at another kid is slim due to my declining egg count. At least with IVF I have a chance of freezing eggs for my future. Is there anything my doctor or I can do for the insurance to go straight to IVF?

Nick:

Ya, there’s a process in place. Your doctor can appeal to say that it’s medically necessary to skip the IUI and it generally involves extra tests. It’s usually pretty difficult, but worth a shot. We tried and failed – had to do 6 IUIs before moving to IVF.

Redditor:

I’m an FCI patient – thank you for doing this. I’m curious what improvements have been made as a result of data analysis?

Nick:

Largely, the improvements have been internal processes for reporting. We’ve been better able to mine our clinical data for research, which is super exciting. Staffing is another strong improvement – we’re able to better predict patient volume at our clinics and assign staffing accordingly.

Redditor:

Staffing is definitely important for a clinic like FCI that sees a ton of patients at once. The less time we have to spend in the maze of packed but silent waiting rooms, the better.

Nick:

Couldn’t agree more. There is nothing worse than waiting for a long time each morning when all you want to do is get to work. That’s been a huge focus for us!

Redditor:

Since instituting Business Intelligence, can you speak to any changes that the care team made when communicating with patients? Were there any surprises?

Nick:

Definitely the institution of our patient portal! Before, it had all be individuals communicating with their individual nurse/physician. But now, we can really see the volume of communication we actually have with our patients. That was the most surprising thing for me.

As a group, fertility patients are incredibly knowledgable and curious. Coming up with new strategies for faster and better communication is on the horizon :)

Redditor:

I’m not an American so I don’t 100% understand the insurance system but I have 2 questions that come up often from our users:

  • Are you aware of any insurance plans that can be purchased privately (not through an employer) that provides infertility coverage?

  • What insurance companies provide the best infertility coverage? Or better yet, what large employers offer infertility coverage in your experience?

Specific questions:

  • How does FCI ensure patients don’t feel “just like a number”?

  • What did being a patient at FCI teach you about patient care within your organization? Did you suggest any changes as a result of being a patient?

Nick:

Great questions!

As far as private insurance, I am not aware of any. Shared risk programs like our Attain program are probably the closest thing to it. Basically, you purchase cycles in advance and get varying levels of refunds if you’re not successful. Obviously the risk being for you that you pay for 3 cycles and get pregnant on round 1.

For traditional insurance companies in IL, Blue Cross is probably up there. But Progyny is probably the best from a patient standpoint. Many large companies contract with them irrespective of their insurance plan to handle all of their infertility coverage. So look for an employer that has them!

FCI instituted the patient portal for you to ask questions whenever you need to. And those questions go to your care team, who is specifically set up to work with smaller groups of patients. There’s also the phone calls that we make for results – it’s a great opportunity to chat with your nurse at a dedicated time. Lots of options for communication!

Lastly: being a patient taught me a TON! I talk about it all the time. Our experience has been pretty good thus far, so there wasn’t a ton to change. I think it helped with a lot of reassurance that we’re doing the right things.

Redditor:

This may not be useful to you depending on what state you’re in, but private insurance plans sold on the health exchange marketplace in states with an infertility mandate are generally required to comply with whatever the mandate stipulates. A lot of people don’t realize they can enroll during open enrollment into a plan with coverage even if they already have insurance through their job (that may not have to comply with the mandate of their company is headquartered in another state or is fully-insured or some other loophole). It may not be the best option if you have employer-based coverage and make an average income, as you won’t qualify for federal subsidies to offset the cost, but even a high premium and max out of pocket costs (deductible and co-insurance) are often less than paying for IVF fully out of pocket. Just throwing that out there for informational purposes!

Nick:

Thanks for sharing that! I had no idea that you were able to purchase from the exchange if you have insurance through an employer. Learn something new every day…

Redditor:

What kind of mistakes can occur in the lab processes (from Egg Retrieval through the PGS testing)? (I’m confident that your team and every other lab does what they can to minimize mistakes, but errors certainly occur. I’m just curious about the nature of such mistakes/errors/problems.)

Also, you noted below that you think IF treatment should be considered medically necessary. If all treatments were required to be covered by insurance, would that just mean that prices rise and insurance companies and patients (with co-pays, deductibles) end up paying more anyway?

ETA: Thank you so much for offering your time for this AMA! I’m very thankful for all the clinics and offices and labs that exist that can increase our chances. :)

Nick:

Obviously bad things can happen. But we do our everything we can to minimize risk. Our lab follows a very strict chain of custody and quality control process with every sample. And we continually evaluate these processes and continue to train our employees as well. Patient verification with asking name and checking wrist bands, showing documentation on the embryo dish before transfer, just to name a few steps. And then the big question we have gotten recently is the storage procedure. Here’s some more info on that: https://fcionline.com/treatment-options/egg-freezing/cryo-storage-lab-safety-update/

As for pricing, I doubt it would go up. It would certainly increase demand for services, which generally speaking, drives prices down. But you’d also have to start talking about profit margin to keep the company in business, so there’s definitely a floor. I hope we find out soon!

Redditor:

My first cycle was non-ICSI and got 6 of 8 mature fertilized. My second cycle, I paid for ICSI out of pocket just to possibly increase that percentage just a bit more.

I happen to get 8 mature again for my second cycle, and only 3/8 fertilized by ICSI!!!

I can’t help but think a junior embryologist did my ICSI 😣. I tried inquiring about what the eggs were like, did they look funny, did they fall apart when injecting, etc, but it’s like the doctor can’t talk to the lab! 😡 (and it’s the lack of info that’s more upsetting than the fert rate itself)

Nick:

Ugh. That makes me sick thinking about. But I will say: I don’t know what clinic or lab you went to, but it almost certainly wasn’t a junior embryologist making a mistake. I mean, things can happen and unfortunately do happen. Embryologists are usually great at what they do. And they practice on donated eggs/embryos hundreds and thousands of times until they get the technique down.

Were I in your position, I would ask to have a consult with the doctor and let the clinic staff know in advance that you’d like to discuss your fert report and talk about egg health. Unfortunately these things happen and sometimes you get 6 fertilized and sometimes only 3. Everyone is different, but we went from 0 mature oocytes (and cancelling the day before retrieval day) to 16 fertilized in a span of 6 months. So things definitely can change on a dime.

Keep at it and good luck!

Redditor:

As the one (mostly) watching your partner go through the IVF process – what were your biggest fears or challenges with it all?

Nick:

I didn’t want to watch her blame herself. Obviously it’s not her fault, but it’s hard to not be successful at literally the one human function we, as humans, are put on the planet for. She handled it very well, though, and took a very well reasoned approach to the whole deal. So I am super proud of her.

My challenges were the financial aspect and working with the clinic (before we switched to FCI) to get our insurance to cover procedures and such. Not a pleasant job.

Also: learning to give those big PIO shots. Man, are those intimidating. I practiced on an orange and on pork roasts.

Redditor:

Is there ever any flexibility with how you bill? Like- a blood test- could that be billed under general instead of fertility? And can you ask billing people to do stuff like that? Most of us don’t have insurance that covers IF or have a cap.

Nick:

Not really, unfortunately they [insurance companies] have seen those tricks before. They know we’re a fertility clinic, so they know what’s up. Though many plans cover the diagnosis or treatment of infertility, just not the actual procedures themselves. That’s where your clinic can ask about the coverage of specific CPT codes they’re working with.

Redditor:

What are some ways patients can save money on their care (if no insurance coverage obviously).

Do fertility clinics have a huge mark-up or it just my viewpoint of that? At $200-300 an ultrasound/bloodwork visit plus retrievals and transfers at thousands a piece (without having to go through insurance for most of it) it seems like it would add up quickly. And what goes into say the “embryologist/laboratory fees” which can be like $6-8K for a retrieval?

Nick:

I’ve been told that if we “just relax” we’d have saved a TON of money on treatment. Didn’t work for us, but you never know. Figured I’d share. But in all seriousness, I think I shared a link below, but: https://fcionline.com/financial-guidance/payment-programs/. Look into payment programs and medication discounts. Those are going to be your best friend.

The mark-ups are really not that high, and I was expecting to find out when I first came on board. There are tremendous fixed costs within the industry – lab space, employees, software, consumables, marketing – and that accounts for the price structure. So a $300 ultrasound isn’t just for the 10 minute procedure. It’s the infrastructure that got you to the room to be able to do it and continue on. Same with the lab fees. That lab equipment is really expensive! And so are our lab team members, who I think are the best in the business.

Redditor:

Regarding mark-ups… I wonder if areas/states with more coverage tend to have higher costs than areas that don’t, since they’ll bill the insurance company.

Nick:

Illinois is a mandate state – meaning employers must cover infertility (with some exceptions) and our pricing is pretty close to national average. But that’s just one data point out of many clinics. We don’t charge more because the insurance companies are paying, contrary to popular belief. We have set contracts and then, separately, an all-in cash price if you are paying out of pocket.

Redditor:

Hi Nick, I have two questions:

  • Does FCI create predictive models for outcomes based on different patient characteristics and if so, could patients have access to those modles?

  • Would it make sense to track data on supplements that patients are taking? With that kind of volume I think a lot of helpful data could come out of it.

Nick:

We don’t currently have it set up, but there are companies in the space that work with fertility practices. We’ve definitely been in conversations, so it could certainly be a direction we move in.

As for the tracking data on supplements: that’s just one direction we’d like to move! We just completed a study on yoga (https://fcionline.com/fertility-blog/new-study-stress-yoga/) and finds that yoga had a 20% impact on reducing stress during treatment. Research is very important to FCI!

Redditor:

Why do you think insurance companies don’t cover PGS testing? Wouldn’t it be advantageous to have immediate successful transfers?

Nick:

That’s a good question. PGS/PGD is still in it’s infancy, so to speak. So yes, it would be advantageous, but there’s risk involved, too. It’s not just a simple cell extraction – you’re literally taking away a part of the embryos you worked so hard for. Not to dissuade anyone from doing it, but unless there’s a specific need (recurrent miscarriage, known carriers, etc) most of the time we don’t recommend it.

We personally did it and I was terrified the whole time waiting for results and freezing.

Some insurances do actually cover PGS/PGD. In the ICSI example, the male generally has to have back-to-back semen analyses warranting ICSI’s use. Just have to prove it is medically necessary to take the extra step. We definitely do a TON of ICSI here.

Don’t miss our other Reddit AMAs during NIAW:

Dr. Edward Marut: Thursday, April 26 from 2-3pm.

Dr. Jennifer Hirshfeld-Cytron: Friday, April 27 from 12:30-2:30pm