Infertility treatment can be a criminal's gold mine

It's interesting to see how public health problems affect insurance costs and open doors to healthcare fraud. Infertility treatment is one example.

Roughly 20 percent of American women between the ages of 35 and 44 sought infertility treatment between 2006 and 2010, according to a national public health action plan by the Centers for Disease Control and Prevention. Though many insurers cover infertility testing and diagnosis, few provide benefits for costly in vitro fertilization cycles.     

Yet if more insurers covered these services, lower healthcare costs might result according to the findings of a Canadian study released earlier this year.

"This [study] confirms what a lot of IVF practitioners have held in the U.S.: That with insurance coverage, single-embryo transfers are more likely to be done, which is going to lower multiple birth rates which is safer and less expensive," Bradley Van Voorhis, director of the IVF Program at the University of Iowa Carver College of Medicine, told Reuters, FierceHealthPayer previously reported. 

Silicon Valley employers are adding a slew of infertility-related services to their benefit packages to stay competitive in the race to recruit talented engineers, noted Reuters. Massachusetts-based insurers have included infertility treatment benefits in individual plans sold through the marketplace, as FierceHealthPayer previously reported. And niche-market companies selling specialized insurance for IVF needs have mushroomed. 

If the tide is turning to make infertility treatment benefits more accessible, insurers need to mitigate fraud risks that come with that development.    

Because infertility treatment coverage varies by state, for example, payers offering these benefits need to watch for enrollment fraud; customers may falsely claim to live in a state where assisted reproduction benefits are mandated.     

And if you think drug diversion is only for narcotics, consider this: Heidi Benham of Hackensack, New Jersey was sentenced to three years in prison and made to repay more than $518,000 to her insurer after executing a multi-year fraud scheme involving fertility drugs, the Food and Drug Administration announced.

Benham was an infertility treatment patient who called specialty pharmacies posing as a doctor's office employee. She told pharmacies the physician had prescribed or authorized refills of her fertility drugs. Pharmacies dispensed these medications and claimed payment for them through Benham's insurer. Meanwhile, Benham sold the drugs for profit to people all over the country through internet classified ads she posted on bulletin boards.

Fraud is an opportunistic crime. A large-scale public health problem that people are willing to throw massive amounts of money at is sure to be targeted.

Capitalizing on the deep longing many people have for a biological child and their willingness to do whatever it takes to achieve that dream, criminals run all sorts of fertility-related scams. Con artists sell mega-vitamins that "guarantee" pregnancy. Hucksters write the "definitive" guide to conception filled with "secrets" your doctor won't tell you. Fly-by-night clinics say their services will result in pregnancy within 30 days or you'll get your money back. Criminals sell counterfeit drugs online. Phony fertility websites trick people into disclosing personal health information, and they become victims of medical identity theft later.  

These scams make me appreciate the role insurers play in protecting customers from quacks and quackery. That's one reason insurers have credentialing requirements for network providers. Payers are often criticized for not covering experimental or investigational treatment, but the same policies customers complain about steer them away from exploitation by those who promise what they can't deliver. And regulatory requirements for accuracy in product marketing materials help shield customers from being duped by deceptive ads.

People and programs shouldn't be swindled under the guise of hope. When it comes to infertility treatment benefits, we must be vigilant. - Jane (@HealthPayer)