Broken Insurance Processes, Rising Costs, and the Fight for Financial Survival in Fertility Care
The financial operations of fertility clinics across the United States are facing increasing pressure as revenue cycle management (RCM) becomes more complex. "Revenue cycle management is a huge pain point for a lot of IVF clinics," said Cynthia Hudson, VP of Clinical Strategy at TMRW Life Sciences and founding partner of Perch Fertility. "The very nature of the fragmentation of services makes it extraordinarily labor-intensive for clinics to manage insurance claims."
Disjointed Insurance Plans: The Revenue Cycle Nightmare
Unlike countries with nationalized healthcare, the United States relies on a patchwork of employer-sponsored and state-provided insurance plans. Even within a single provider like Aetna, Hudson noted, "there's probably thousands of different plans depending on the sponsor." This variability forces clinics to invest substantial time and personnel into verifying coverage for each patient.
RCM in fertility care generally follows three key stages: benefits verification, pre-authorization, and claims management. Each step introduces potential delays, errors, and administrative costs. Benefits verification requires staff to confirm coverage details, often navigating insurer-specific portals or calling directly to clarify plan terms. Pre-authorization then mandates the submission of detailed clinical documentation to justify proposed treatments, with no guarantee of approval.
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Gaia is only partnering with fertility centers with excellent success rates. Get in touch with Gaia to see if you are eligible to:
Protect your patients from unnecessary financial risk
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Improve your revenue cycle management
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Just email Kay Colegrove, to see if Gaia can start sending you IVF-ready patients.
Some Clinics Opting Out of Insurance , “No Way to Be Transparent With Commercial Insurance”
The final stage, claims management, presents its own set of challenges. "Submitting the bills with all the diagnostic and procedure codes doesn't mean they're automatically going to get paid," Hudson explained. Denials can stem from reasons as nuanced as incorrect diagnosis codes or missing documentation. "Then it falls back on the clinic to figure out why a claim was denied, gather more records if needed, and resubmit."
For some clinics, the burden proves too great. "You will find some fertility clinics that do not accept any insurance," Hudson said. Clinics may choose to operate as cash-only practices to avoid the operational drag of insurance processing, despite the potential for lost patient volume. Others selectively contract with insurers that offer more predictable reimbursement processes.
These operational hurdles directly affect patient access to care. Patients with insurance may find their coverage unusable at certain clinics, while others face opaque cost estimates due to insurers' variable reimbursement structures. "There's no way to be transparent with commercial insurance," Hudson observed. "I can be really transparent with my cash pricing. But when it comes to insurance, I have no idea what I'm going to get reimbursed until we go through the process."
“The System Is Broken”: Outcome-Based Solution Takes Over
Some financial solutions are emerging that simplify aspects of the process by offering employers streamlined fertility coverage packages. Such arrangements create clearer parameters for coverage and reduce the administrative burden on clinics.
Another innovative model comes from Gaia, which applies a pay-for-success approach to fertility financing. "I love it," Hudson said. "The concept of paying for an outcome is the right way to think about it. As a clinic, we should be incentivized to get you pregnant and out the door as quickly as possible." Gaia's value-based model provides patients with financial clarity while aligning clinic incentives with successful outcomes rather than procedural volume.
This approach helps bridge gaps in coverage for patients without traditional insurance benefits. By offering a predictable cost structure based on outcomes, Gaia reduces the financial uncertainty that often accompanies fertility treatments.
Still, structural challenges persist. "The system is broken," Hudson said. "Access to fertility care depends on where you live, how much money you have, and who you work for. Until we collectively agree on how to address these issues, clinics will continue to bear the brunt of the complexity."
Get More IVF-Ready Patients Now.
GET PAID FASTER
Gaia is only partnering with fertility centers with excellent success rates. Get in touch with Gaia to see if you are eligible to:
Protect your patients from unnecessary financial risk
Fill your schedules with IVF-ready patients
Improve your revenue cycle management
Increase your patient satisfaction scores
Just email Kay Colegrove, to see if Gaia can start sending you IVF-ready patients.