Financing & Insurance

Adore believes we can make parenthood available to all.

Adore was established to not only provide a more intimate, boutique vibe for patients needing fertility care in the Lowcountry but also to make costs more affordable and transparent. The fertility industry and its pricing have run unregulated for quite some time, however, the costs of running a clinic have decreased over the last 10 years. With that said, many fertility clinics still are not decreasing their prices for their patients and/or are not transparent about their pricing. This results in more patients being priced out of having a family of their own or patients being left with bills they never expected to get. Adore believes that with transparency on costs, transparency on insurance coverage, and providing more affordable self-pay package prices we can make parenthood available to all. We believe that fertility centers can keep their doors open and make profits without taking advantage of our patients.

At Adore, we realize that even our lower-cost self-pay packages can still be quite an investment to patients. We have partnered with CapexMD to help with financing so more patients can take advantage of our pricing.

Frequently asked questions answered by Adore

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How do I know if I have fertility insurance coverage & what is covered?

Just because you may have medical benefits with a said insurance company does not mean you have fertility benefits. It is important for patients to understand what it means to have fertility benefits and what exactly those benefits cover as no insurance carrier, or one policy is the same. Medical insurance coverage for infertility treatment and for IVF can be quite complicated. Some insurance plans will cover no fertility services, some pay for just the workup/testing but no fertility treatments, some pay for any aspect up to maximum coverage costs (such as up to $15,000 maximum), and many are somewhere in between. This can make coverage quite confusing.

About 15 states have some type of mandate for infertility insurance coverage, South Carolina is unfortunately NOT one of these mandated states. In states without any infertility coverage mandate such as South Carolina, most insurance plans do not help much with payment for fertility testing, treatments, and/or IVF services. Even the best insurance plans in our state do not fully cover the costs of IVF and medications (outside of plans such as Progyny).

When checking with your insurance, it is important to call and speak to someone directly about your covered services. Important things to ask are:

1) Do I have any deductibles to meet before I get coverage?

2) Do I need any prior authorizations before I do a work-up/evaluation or treatment? Prior authorization is a form that must be filled out by the clinic with justification for a test or treatment. If your insurance requires this, you must have this submitted and wait until it is approved prior to testing/treatment or you may not get coverage.

3) What testing/evaluation components are covered for fertility AND what ICD-10 codes need to be used to ensure coverage? Questions to ask: Are fertility labs such as FSH/LH/Estradiol/AMH covered? Is the tubal patency test known as the HSG (hysterosalpingogram) covered?

4) What treatments are covered and do I have to complete certain treatments FIRST before I can move to another treatment option? For instance, some insurance carriers require patients to do medications alone (Clomid or letrozole) before they can add in IUI (intrauterine inseminations) or IVF (in vitro fertilization). If you do not complete these steps first, an insurance provider can deny your coverage completely!

Ultimately, despite prior authorizations or claim submissions, payment is never guaranteed by your insurance company and insurance companies can change their coverage. It is very important for you to stay on top of your coverage if you want to be able to use it to your benefit! Adore has been able to set lower self-pay costs in order to avoid some of the uncertainties with insurance companies and to avoid our patients having to pay out of pocket for high deductibles for low coverage overall. Many times (most times) self-pay options save our patients money, time, and the stress of uncertainty with insurance.

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What does it mean if a clinic is in-network or out-of-network?

We (Adore) can see any patients with any type of insurance plan; however, submitting & what you get covered by insurance can be different pending if we are considered “in-network” or “out of network”. When a doctor is “out of network” it does not mean that the insurance company will not pay for the services at all. If we are not “in-network” with the plan, and you have fertility benefits that you want to try to use then you MAY have a higher amount of “coinsurance” (what you are expected to pay out of pocket) as compared to if they went to a doctor that is “in-network”. Furthermore, if we are not “in-network”, we cannot submit claims on your behalf. However, just because you come to an “out of network” clinic does not mean you cannot get some reimbursement from your insurance. Similarly, just because you go to an “in-network” provider does not mean you will not pay high out-of-pocket costs or the costs may still be higher at an “in-network” clinic compared to Adore’s costs due to our low-cost fee structure/transparent pricing. Pending your insurance plan, deductibles, and what is charged to the insurance company for your treatments, you can still end up paying a lot out of pocket. Adore will help you decide how to best approach in vs out-of-network options vs our self-pay options to save you money and get the best out of your benefits.

We strongly encourage our patients to take advantage of our second opinion financial consults to see if Adore can save you money!

If Adore is not “in-network” with your plan, this is what we suggest:

1.) Check your deductibles. Sometimes you have a deductible for basic medical and one for fertility. It is not always one lump sum. If you haven’t hit your deductible(s) then you will be paying out of pocket for your workup/initial treatments regardless of where you go! You can do this at an in-network or out-of-network clinic; however, Adore’s self-pay prices are drastically lower than our competitors (approximately 30%) so you may be able to save money by not using insurance!

2.) If you have low deductibles (or you already hit them!) and your workup can be fully covered by an “in-network” clinic only, get your workup done and bring us the results. We will give a free second opinion financial consult review so you can see how we can save you money in comparison to our competitors.

3.) Find out what options you have if you want to go to an “out of network” clinic for your IVF Treatment. For instance, many times you can apply for an exception to your insurance company policy to use an “out of network” clinic (since our self-pay prices will be likely cheaper for you!) and they will allow you to submit your bills from self-pay and get some or all of it reimbursed by your insurance. Furthermore, just because we are an “out of network clinic” does not mean you cannot use your fertility benefits for the prescriptions (to a specialty pharmacy) while saving you money on your out-of-pocket IVF expenses, and many times, this benefit can last a lot longer for you!

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How do I use my fertility coverage to maximum benefit?

Many times, by paying self-pay discounted prices and using your insurance benefits for your prescription costs, you can actually save money. It is not a one size fits all scenario. With that said, we strongly encourage patients to get a financial consult and discuss the best way to use their insurance (if they have fertility coverage) to their max benefit.

Because Adore’s self-pay fee structure is discounted, we beat competitor pricing 9 out of 10 times. Furthermore, what has been frustrating is that we have seen many patients who attempt to use their fertility benefits end up paying more out of pocket than they would have had they used our discounted self-pay route. Yes, that is correct. Just because you have fertility benefits or have max coverage up to $15,000 does not mean you still won’t be left with a steep out-of-pocket bill after the fact!

For example, let’s say you have coverage for $15,000 maximum in fertility benefits. A clinic self-pay discounted rate may be $8000-13,000 for an IVF treatment; however, this is not the cost that gets submitted to your insurance. Remember self-pay discounts are discounts for a reason. They are set up to save patients money and save the clinic time/money by not having to fight with insurance companies for coverage. In the medical industry, when we submit claims to insurance, we are required to use something called CPT and ICD 10 codes. Each code has a different allotted charge attached to it that an insurance company is willing to pay (And each insurance company’s agreeable rate is different per insurer and per policy). Insurance companies are not required to cover each code submitted, and if your insurance does not, then you are left with those costs to cover on your own. Furthermore, insurance companies do not have to share these rates with the doctors/clinics, so we cannot predict how little or how much you may end up paying out of pocket in the end! Ultimately, what may be charged to your insurance company based on their contracted rates for all the codes submitted for IVF could be >$20,000-$30,000. Remember you still have prescription needs that will range from $3000-$8000 (pending the dosing of medications you need, individual to you). Having that $15,000 max will all be used in your benefits for the IVF cycle (that $20,000-30,000 cost attached to the codes submitted) and you may be left with $5000-15,000 out-of-pocket costs for the IVF cycle alone. Then you still have medication to pay for. This leaves you with out-of-pocket costs ranging from $8,000-$23,000. But you had benefits, right? We agree, that this is not fair nor transparent! At Adore, we realize that the pricing and coverage costs are not transparent to patients when attempting to use benefits. Therefore, we set up our self-pay fee structure to lower costs overall. We can do this at a lower cost because we are not chasing insurance companies to fight over benefits. With this said, you CAN STILL USE YOUR BENEFITS to cover medications costs and your benefits sometimes can go a lot further this way!

We strongly encourage all patients to have a financial consult/review before they proceed with costly treatments if they have any fertility coverage so they can use their fertility insurance to their max benefit.

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Why does Adore not accept multiple insurance carriers?

When we opened our doors, it was our intention to accept all major insurance carriers, however, over the last year, we have seen our patients have higher/unexpected bills trying to use their insurance coverage, leaving all of us frustrated. Outside of a few good insurance plans, some of the best coverage in the state (BCBS SC, Aetna, Cigna) still leaves our patients using up ALL their benefits in the first/retrieval IVF cycle and leaving them with the same (or higher!) out of pocket costs than what our self-pay structure would have cost them. By taking out the insurance middle person, we have been able to keep our self-pay costs down and transparent.

We have flat rate pricing so that our patients do not end up with unexpected bills on the back end. We have flat rate pricing so our patients can plan their costs ahead of time. We have flat rate pricing so patients can save money and still use their fertility benefits to cover the medications (cost $5,000-$7,000 for their first IVF cycle, and still have benefits to cover their transfer cycle medications $1000-2000). Because fertility benefits, even with the best plans, leave unknowns to our patients and rarely cover everything, we have decided to go a different route. We save money taking out insurance and then can pass on those savings to our patients. Whether Adore is “in-network” or accepts your insurance or not, we strongly encourage patients to set up a consultation to discuss pricing before they commit to a clinic as 9/10 times we will likely come out saving you money!

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How does Adore handle insurance claims if in-network?
At Adore, we require all patients (in- or out-of-network) to pay the self-pay price upfront for their tests/treatments as a deposit since we ourselves do not know what will be fully paid out by insurance. From there, we offer two options:

1) We submit prior authorizations for any tests/treatments your insurance requires. You take advantage of our self-pay bundle discounted rate we offer and use your fertility benefits on your medications. We then give you your self-pay invoices with your ICD10/CPT codes to submit to your insurance for reimbursement on your end. This allows you to take advantage of our transparent self-pay pricing and not be stuck with higher-cost bills by your insurance (See "How do I use my fertility coverage to maximum benefit?" FAQ).

2) We submit prior authorizations for any tests/treatments your insurance requires. You pay our self-pay price upfront for tests/treatments as a deposit. We submit each visit/code to insurance (not the bundled discount). Pending your insurance and Adore's contracted rates, pending your deductibles or co-insurance, insurance will pay claims, and any codes they pay claims on, you will get reimbursed. However, if the rate your insurance pays is higher than our self-pay pricing, and you have a co-insurance or deductible to hit, you may owe more money to Adore in the end. These are the uncertain risks involved with insurance sadly. Please consider a consult to review these options in detail. Our goal is to save you money in the end!

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What insurance is Adore in-network with?
Adore Fertility is currently only in-network with certain plans with Aetna and UnitedHealthcare. Please note, if you are looking to see if you have coverage or if we are in-network on your insurance website search, you must search for Adore Fertility as the clinic, not Dr. Jeris Cox. If you search for Dr. Jeris Cox, you will find there are several plans she is/was in-network with as an OBGYN, however, these plans do not cover fertility coverage.

With this said, Adore Fertility is moving to fully self-pay discounted prices in Jan 2023 so you can still use ANY fertility benefits on your prescription fertility needs and save money. Please schedule a consult to see how we will still save you money!

“Dr. Cox is by far the best doctor I have ever had! She was with us while she was on active duty, caring for military families. Not only did she stick by me and my husband through all the years of my fertility journey, but she also delivered my handsome little boy!"

Our Practice

Location

1280 Hospital Drive, Suite 300
Mount Pleasant, SC 29464

Make an Appointment

Call 843-990-4500 for an appointment. We look forward to serving you!

Open Hours

Monday - Thursday: 9am - 4pm
Friday: 9am - 2pm

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