DISCLAIMER: Today’s Advertiser helped make the production and delivery of this episode possible, for free, to you! But the themes expressed by the guests do not necessarily reflect the views of Inside Reproductive Health, nor of the Advertiser. The Advertiser does not have editorial control over the content of this episode, and the guest’s appearance is not an endorsement of the Advertiser.
What should you take into consideration when tackling the insurance companies for fertility service reimbursement? This week, Griffin hosts Boston IVF’s CEO, David Stern, to discuss the ins and outs of maximizing insurance reimbursements, and the barriers you may not have considered. Tune in to the latest episode of Inside Reproductive Health to hear more.
Listen to hear:
How to position both insurance companies and employer carve out companies to get better pay out rates
What data you need to share to get the best reimbursement rate.
About the differences in negotiating when it is a global fee vs. different CPT codes and what state mandates do to codes.
David give examples of some mistakes that can happen, ie: money loss, when billing uses incorrect CPT codes.
How Boston IVF negotiated a 67% increase in reimbursements.
About the principle of disruptive innovation, why traditional fertility companies were late to the fertility game, and how others cashed in.
David Stern’s Info:
Website: https://www.bostonivf.com/
LinkedIn: https://www.linkedin.com/in/david-stern-mba/
Transcript
David Stern 00:00
In an insurance situation, you almost have to be an accrual because what you're doing is you're performing services, but you're not getting paid maybe until the end. And so, if you think about it from a calendar standpoint, somebody gets there. Day one, they have their period, they start drugs in the middle of the month, you start them as an IVF case in February, but they're not going to complete the process until March. Or if it's a freezer, it might be April or May. And so if it's cash, you they're not paying you cash when they start in February, they're getting approved, so their prior auth approval, you know, you're going to get some payment from them, but you also have cancellations. So if a patient gets cancelled, you don't get the full amount for IVF because they haven't gone through the full cycle.
Sponsor 00:48
This episode is brought to you by Univfy. Email Dr. Yao at mylene.yao@univfy.com. Or just click on the button in this podcast, email or webpage for your free employer benefits, tips and strategies. Today's advertiser helped make the production and delivery of this episode possible for free to you. But the themes expressed by the guests do not necessarily reflect the views of Inside Reproductive Health, nor of the advertiser, the advertiser does not have editorial control over the content of this episode. And the guests appearance is not an endorsement of the advertiser.
Griffin Jones 01:30
Lucky you, look at you, lucky, you get to listen to this episode about insurance reimbursement today. I know try to calm yourself. My guest for today is David Stern. You might know David Stern, he was at EMD Serono for a number of years as Senior VP executive VP in different areas there worked at high levels of leadership and other parts of the industry. But most of you know him now going on his fourth year as CEO of Boston IVF. I tried to get as much concrete advice from David as I can about how you position two different payers, both insurance companies and employer carve out companies for getting higher reimbursement rates. We talk about the data that you need to share with them to get the best reimbursement rate we talk about the difference in how you negotiate when it's a global fee versus different CPT codes. We talk about what state mandates do to that dynamic global fee versus individual CPT codes with particular emphasis on New Hampshire and New York being among the most recent David gives examples of some of the mistakes that practices make when they're billing to the wrong CPT code and losing a lot of money. Because of it. He talks about a particular example where Boston IVF was getting probably under 50%, of what the cash pay rate would have been from reimbursements from different insurance companies and what Boston IVF did to negotiate 67% increase in reimbursement. We talk about the leverage that you have as a clinic, whether you're in a large market with a number of physicians, or if you're in a smaller market with fewer providers. I asked David, if it's really the case that fertility networks can help clinics negotiate with insurance companies, if they don't have a lot of providers in that specific geographic area? Is it irrelevant how many providers you have across the nation? If you only have a small percentage of the market in a particular geographic area, David respectfully disagrees with the position that I presented given from a fertility practice owner and he says why we talk about the principle of disruptive innovation, why traditional insurance companies were late to the fertility game while companies like progeny kind body and carrot were able to grow massively. We talked about the differences between negotiating with traditional insurance companies versus employer benefit companies. And then I asked what do you do when you have an employer benefits company or anyone for that matter that comes in hot the first year, but then the next year slashes reimbursements in year two, finally, David talks about the game of chicken that happens in negotiation, how you learn your own costs, how you learn what you're being currently reimbursed, and how you think about that, as you discern your leverage versus what's worth it to your practice, what's worth it to your patients, and what might be worth it in the future. I hope you enjoy this episode with David Stern. Mr. Stern. David, welcome back on to the inside reproductive health podcast.
David Stern 04:23
Thanks, Griffin. Glad to be back on. Thanks for having me. Again.
Griffin Jones 04:26
I want to ask you a lot of questions about insurance today, because it's not my sphere, I get questions frequently. And it might be yours being the CEO of a very large fertility clinic group. So I want to start off with some context and hopefully not be too general. It might seem obvious, there's more insurance coverage than there had been there's more employer benefits and more employer benefits companies, but it's specifically as you can be what's happened with insurance coverage in the fertility field in the middle last five years.
David Stern 05:01
The insurance coverage has expanded, which is very good for patients. It's increasing access for patients, which is fantastic. And there are a couple reasons for that. As you mentioned, it's become more popular to offer fertility benefits through an employer through an employer carve out companies, some of the traditional national insurers like United Healthcare, Aetna, Cigna are also trying to make their own kind of carve outs for fertility and offer it in a little bit of a different way than they historically had. And then there are also state mandates. And I think that's something we should talk about, because in general state mandates, most people feel are very good. And I think they are because they offer access. But when a state passes a mandate, there is a slow period of time where people think, okay, the mandate passes, for example, New Hampshire in New York passed a mandate went into effect in 2020. But it took the insurance companies time to catch up, and in some cases, they still haven't caught up. And so there's this perception, I think that we have from whether it's resolved as a lot of lobbying and does a fantastic job, but patients underestimate the amount of time that it takes once the mandate is in place to actually mean that you're going to get coverage. It's not like it starts in January. And right away, you can start doing IVF January seconds.
Griffin Jones 06:35
Tell us what you mean by the insurance companies not having caught up what does that look like?
David Stern 06:41
I think it has to do with the process by which prior authorizations take place. First mins take place insurance companies have NVF centers or fertility practices in their network. All of that takes time, especially if you're going from a state that didn't have a mandate to now having having a mandate, it's almost going from zero to 60, if you're in like New York had a fertility mandate, but didn't include IVF. And their update to the insurance mandate was to include IVF coverage. So that's a little bit different, because the Fertility Centers were maybe the maybe already involved or taking insurance. And the only difference was they could now start billing for IVF procedures were before they wouldn't be approved, or they wouldn't be paid for is part
Griffin Jones 07:30
of the reason why it takes so long to catch up because of variance in the way the legislation is written. So why can't a Blue Cross a really large company that does have experience with mandates in Illinois and Massachusetts, once it hits in New York or New Hampshire? Why can't they just replicate that process at scale? What what are the variables that's causing them to be slow?
David Stern 07:55
I'm not an expert in Blue Cross. But I think it's an excellent example. Blue Cross operates very locally. And Blue Cross of Massachusetts is different than Blue Cross of Illinois. In fact, I think they have different ownership structures. And so just because you have Illinois, Massachusetts, Maryland, New Jersey, where they're all blue crosses, like New Jersey, Blue crosses Horizon, it's Brandon horizon. And I don't know if it's a different ownership structure. But it's not as simple as just saying, hey, let's roll this out, because we have it in Illinois. So let's just do it in Massachusetts, the national companies like a Cigna or United, it's much easier for them because it's national. And so they're following the different regulations. But an important consideration is that each state has a different mandate. And this is where it's also very confusing for a lot of people is just because you think it's covered. It could be based on the number of insurance or a number of employees. So for example, one state I think Massachusetts has, if you have more than 100 employees, you have to have coverage. In another state, it's 50 employees. But if you think about it, if you're in a state like New Hampshire, a lot of employers, local employers in New Hampshire may be law firms or small companies that don't have 50 employees. And so they fall outside of the mandate. Whereas in a bigger state, like a, you know, New York, maybe if it's 50 employees or 100 employees, it's easier because there are a lot more bigger size companies.
Griffin Jones 09:36
And it seems that even that legislation could be written differently. It could be maybe in one state, if they're headquartered in that state versus if they have an office that has 50 employees based in that state. Is there variance there as well.
David Stern 09:51
Typically, if you're headquartered in that state, and you offer that insurance, then you're covered by that state, it becomes more complicated again, if you're offering a lot Local plan in a different state outside of the mandate, and it might be up to the different state regulations.
Griffin Jones 10:07
A Boston IVF has offices in how many states now
David Stern 10:09
we have eight states, offices in eight states.
Griffin Jones 10:13
How many of those are non mandated states?
David Stern 10:17
Four of them are non mandated. So Ohio, Utah, Indiana, and North Carolina.
Griffin Jones 10:24
Okay, so we can kind of explore mandated versus non non mandated and we can even explore a little bit within mandated states. What because Boston IVF has offices in New Hampshire and New York, which as you said more recently released their mandate in 2020. What was the biggest changes that you all had to adapt to? In those two states,
David Stern 10:52
when you have a state mandate that takes effect the insurance companies and this is one of the things that I mentioned about catching up, oftentimes, insurance companies will get reimbursed that you build based on a CPT code. So each procedure has a CPT code, a blood draw, an ultrasound, an egg aspiration for a retrieval, those all have CPT codes. In the more advanced states where the mandates have been around for a long time, there's something that's called a global fee. It's an S code. So the S code for IVF is s 4015. And that includes all the ultrasounds all the physician visits, all the blood draws, the egg retrieval, and oftentimes, the fertilization, all the things that happen in the lab, and then the transfer. And that's global, in that one CPT code. And what that does is it actually places the IVF Center at risk, because you're paid one fee for that IVF cycle, as opposed to in states where oftentimes when you have a new mandate, you're still submitting CPT code. So if you do seven ultrasounds, you submit the CPT code for an ultrasound for seven times for a patient and the insurance will pay seven ultrasound visits or blood draws or whatever that is. So there's a difference between CPT code billing and global billing. And it puts more onus on the IVF center and more risk when you're doing a global bill because they're giving you one fee. And then you have to figure out how do you manage the patient, the proper clinical way, but also maybe you don't need to bring them in everyday for an ultrasound and a blood draw. And I think in some of the practices that have been in mandated states for a long time, you see a little bit of a different type of scenario than you do in cash state where they're bringing patients in all the time for bloodwork and ultrasounds,
Griffin Jones 12:50
does that apply to the employer benefits company as well, if they're covering people in mandated states do they also need to go by the global fee structure,
David Stern 13:03
I would say the way that they operate can be different, but the Centers of Excellence the progeny is the wind fertility, the I would say kind body all have a global fee. And so you're getting reimbursed based on that global fee for an IVF case?
Griffin Jones 13:22
How does the process change the workflow process change, whether it be investigating coverage or doing claims when you're moving away from CPT codes and towards a global fee.
David Stern 13:37
One thing that I change is who is doing ultrasounds is a perfect example. In a smaller clinics, in clinics where yourself pay, a lot of times the doctor will do the ultrasound, it's an opportunity for the doctor to interact with the patient. When they're coming in, they can say oh, your follicles are growing nicely, or, you know the follicles aren't growing as quickly as I'd like I'm going to increase your dose, it's an opportunity to have that face to face interaction, even if it's for five or 10 minutes when they're doing the ultrasound scan. In mandated states, you want the doctor seeing patients bringing more patients in into either new patient consults or follow ups. And so you oftentimes will hire somebody to do the ultrasounds for you like an ultrasonographer. So you have multiple patients coming through and that's one of the benefits of the mandates is you have an increased volume. And to do that you need to have different people performing those types of procedures because a doctor doesn't need to do an ultrasound and I think many doctors would actually say there's probably an ultrasonographer that might do a better job of doing ultrasounds and then a physician who is doing it as a way to interact with the patient but not the expert and ultrasonography.
Griffin Jones 14:53
How about on the claim side what information is important to insurance companies?
David Stern 14:59
First and for For most, you have a prior authorization process. And this takes time. And in fact, one of the things that we've seen during the pandemic is, it's taking longer to get patients approved for prior authorization. The good news is that once a patient is prior authorized, then you know that the cycle is going to be paid for. But up until that point, you have to submit testing, you have to submit diagnoses you may have to do, you might have to do evaluation of the uterine cavity, there are different tests that you have to do diagnostic tests in order to show that the patient is infertile. And essentially, you know, has infertility as a disease and is treated and falls under the state requirements for infertility. And it could be due to staffing issues that insurance companies have, but it's definitely taking longer to get prior authorization. And so one of the frustrations patients have as well as IVF centers is when a patient you submit the all the information. And the patient says, Hey, I'm getting my period, I want to start, if you haven't gotten the prior authorization, yet, you can't start because you can't start the process until the insurance company has said, yes, they meet the criteria, we're going to approve that. Sometimes patients will get denied in the prior authorization process. And you have to do a peer to peer one of our physicians has to talk to a physician on the insurance. Oftentimes, it could be based on maybe a BMI parameter. It could be based on age, some insurance companies have cut offs. So if someone's BMI is too high, they'll say no, we want to prove that because the higher the BMI, the less likely the success of an IVF cycle. Same thing with age, we actually had one of our payers who routinely was denying anybody over 40. And so we had a meeting with this payer. And we said, You're denying everybody over 40, we have to take time to have our physician call your physician do a whole appeal process. Why are you doing that? And they said, well, because people over 40 have a less under 5% chance of getting pregnant. So we pulled out our statistics for Sart. And our 42 year old and over had a 15% live birth rate. And we said to the insurance plan, maybe 15 years ago, that was the case. But today, the average in the United States is 10%. So to say that just because someone is 40, that they should be denied, is using old criteria to basically prevent patients from getting coverage for treatment they need. And there's a lot of that happening, where insurance companies typically deny things and then some people will say, Oh, well, it's denied, I'm not going to fight them, I'm maybe cynical in thinking that insurance companies deny things where maybe they shouldn't be in and then they'll approve them on an appeal. So patients and physicians, it takes a lot of the physicians time to do this. But in the end, the patient can get approved and go through treatment. And
Griffin Jones 18:04
who is doing this with the insurance company because you have to deal with each individual insurance company. Right. And so I'm guessing it's not the Claims Representative necessarily working on that one claim, although they have a criteria from the group. But when it comes to something like pointing out the live birth rate of your over 40 demographic, I'm assuming that that's something done on a more global level than just the claims representative on this particular claim. Is it? Is it someone that's director level at your company? Do you have to come in and negotiate with somebody high up on the insurance company side? How does that work?
David Stern 18:44
A lot of times, we have financial counselors, and their job is to work with the insurance company to put the claim in in order to get the prior authorization when it gets denied usually has an escalation process. So we do have a director of financial counselors, a lot of times we have one or two physicians that are specifically the ones who interact with a specific insurance company. So you know, one doctor might be for Blue Cross and other doctor might be for Harvard tufts. And that escalation process will happen at that level. When we have a bigger situation than oftentimes I may get involved and talk to somebody high up at the at the insurance company. We've had a couple of different insurance companies where we'll have our medical director Michael Alper myself, our CFO, and we'll sit down with high level people at an insurance company and that example that I gave you was, are specifically saying can we not have a specific approval for because our success rates are good? Why do you keep denying this? And the response we got from the insurance company was, well, if we give it to you that everybody will will take advantage of it. And we said, why don't you put into fac AI Center of Excellence and specific Basically say here are senators that have a higher success with these patients. So we will, you know, prior author, we won't have to go through an escalation process. And they said, No, we don't think that that's necessary, we'll do that. We want you to continue to have to escalate it through the appeal process. Unfortunately, it's can be very frustrating at times. So
Griffin Jones 20:20
for that particular company, it never was resolved at the global level it oh,
David Stern 20:25
it for that particular company. And what's even worse, is we said, okay, for your people that are going through the prior authorization, who reviewing these, do you have a group that only does fertility patients, and they said, No, we have priority, you know, whoever whenever it comes in, it gets done either alphabetically or by number or whatever. There isn't any specialization. So that's even more frustrating because you have somebody that's approving a orthopedic claim who then gets an infertility claim, and it's just reading off of a list that they have. And so if it says over 40, deny, that's exactly what they do.
21:04
Sponsor 21:04
The fertility field now has really amazing benefits companies like Progeny, Carrot, Maven, and KindBody, and employers really want to know the value of the fertility benefits they offer, and they want to maximize that value for their employees. Still, most employers don't offer unlimited fertility care. There's a financial limit to most employees fertility benefits, employees often exhausts $10, $20 and $30,000 in fertility coverage, because they need multiple IVF cycles and weren't enrolled in fertility coverage. The traditional way of maximizing benefits dollars has been to reimburse providers less, but paying doctors less doesn't add value. Univfy thinks there's a better model to offer the best support to employees, employers and providers. Univfy offers a way to cut costs without penalizing providers. Based on firsthand conversations with benefits decision makers of mid to large sized employers, what employers really want to see is how their employees are supported in the best possible utilization of their fertility benefits. Dr. Mylene Yao,, CEO of Univfy Fertility, has tips and strategies for how to best position to employer benefits companies, and how to best position your employer benefits company to employers email Dr. Yao at mylene.yao@univfy.com or just click on the button in this podcast, email our web page for your free employer benefits, tips and strategies.
Griffin Jones 22:41
I want to ask the follow up question to this in a way that isn't so elementary for the audience, it's necessary for me but help us understand the jigsaw of the process of the that the clinic has in order to be reimbursed where the insurance company's processes on the other side of the puzzle to pay and I'm thinking of it, kind of similarly to AR and AP, we as a company have an AR process multiple and other companies have AP processes. And so we Jigsaw them together? How does that work with in surance companies and with clinics? And well first, give us a little context of that. And then I've got a couple follow ups.
David Stern 23:28
I think it's interesting. And as I've come into this field from the industry side, it was an eye opening and learning experience for me because initially I thought okay, you know, what you're talking about is when do you bill? And when do you receive the cash. And so a lot of centers that are smaller are on a cash based accounting system, right, you basically Bill somebody, you get the cash, you acknowledge that you get the cash. In an insurance situation, you almost have to be an accrual because what you're doing is you're performing services, but you're not getting paid maybe until the end. And so if you think about it from a calendar standpoint, somebody gets there. Day one, they have their period, they start drugs in the middle of the month, you start them as an IVF case in February, but they're not going to complete the process until March. Or if it's a freeze all it might be April or May. And so if it's cash, you they're not paying you cash when they start in February, they're getting approved. So their prior auth approval, you know, you're going to get some payment from them, but you also have cancellations. So if a patient gets cancelled, you don't get the full amount for IVF because they haven't gone through the full cycle. So it becomes very interesting in terms of when do you recognize the Cycle Start? When do you actually get paid for it? And so our accounting group or a finance group is doing that on a daily basis, putting in a claim and we know that At, we actually recognize revenue based on different milestones. So when someone goes to retrieval in our system, we say, okay, they've gotten to that, that point in time that you know, benchmark, which is retrieval, we can, we can recognize a certain amount of that revenue for the IVF cycle at that point, oftentimes, insurance companies, at least some of the ones that we deal with, don't pay you in full until a transfer occurs. So that could either be a fresh transfer or frozen transfer. So if you're doing a Pg t case, and you're freezing all the embryos, you might have started your cycle in February, but you're not getting the PG ta results until April, and you're doing a frozen embryo transfer in April or May. So you don't actually get that revenue. Until the full revenue, you don't get it until the transfer occurs, you may have recognized that it steps along the way. But you haven't actually received the the income
Griffin Jones 25:54
to delay on payment for PGT is one example. You also see a lot of fertility clinics. If you've acquired a few in the last couple years, you're probably going to acquire more in the next couple of years. And so you're looking at these things as you are getting into the due diligence with clinics, what are you seeing that clinics are missing from their processes to protect themselves? What are two or three of the most common examples.
David Stern 26:20
When you're dealing with insurance companies, I think the biggest the biggest opportunity is understanding what you're getting reimbursed for. And you might be billing something, but you're not getting reimbursed at 100%. And so when you're dealing with insurance, if you charge $200 for an ultrasound, and you submit your CPT code for an ultrasound to United Healthcare, Cigna or whoever it is Aetna, you might actually be getting 50% of that they might be paying you $100 Because their usual uncustomary is based on some other, you know, national charge. In fact, this happens a lot. You see ultrasound charges that may be billed and an OB GYN, abdominal scan, and you're doing a transvaginal scan, and you're measuring the size of follicles. And that takes a lot more time than a traditional abdominal ultrasound to just see is there a fetal heartbeat. But they're, they're billing or they're reimbursing you at national CPT code for whatever an ultrasound is. And that's one of the biggest challenges that IVF centers have is their billing, but they're not receiving the payment. So you have to really do a deep dive into what are you getting reimbursed for when you're dealing with insurance companies?
Griffin Jones 27:38
How do you do that deep dive? What does that audit look like?
David Stern 27:41
What we do is we actually looked by each payer, what we've submitted, and what we get billed on a patient level. So we do this, and there's even more challenging. So here's the crazy thing about insurance companies. And again, this this was a major learning for me. You think, Okay, someone has UnitedHealthcare? Everybody's got united, they're going to pay the same? Well, they don't, because the employer may have one of 10 different United plans. And the reimbursement is going to be different based on what that employer has bought from United. So yes, it's United Healthcare. But it could be their premium package, it could be their gold package, it could be their silver package, for lack of, you know, I don't know whether they actually offer that. But you're getting reimbursed at a different percent, based on that gold, silver and platinum. So just because they have united doesn't mean that you're getting paid the same for every United patient. And that was one of the the deep dives that we've done here. Looking at different insurances to understand what are we asking for? What are we submitting a claim for? And then what are we going to reimburse that. And part of the process that we've done is looking at there are certain insurance companies where we were losing money, we were getting reimbursed at a significantly lower rate than what our self, you know, self pay rate was to the point that it might have been under 50% reimbursement. And so we've met with the insurance companies. And it is something I think we should get into Griffin because it's really about understanding how do you position yourself to an insurance company. So we met with them, we said, you're giving us this this reimbursement. We're losing money on every patient. We can't afford to be in your network. We can't afford to treat your patients because you're substantially under we had a plan that was 50% or a little bit more than 50% lower than our average insurance reimbursement, not even self pay, but average insurance reimbursement. So he went to a couple of these insurance companies and present it to their medical director and to their senior level people. And one of the frustrating things was oftentimes it's bad Originally in smaller regional insurance plans, their medical director was a primary care doctor or an ER doctor who doesn't know anything about infertility. You explain to them the process of IVF and embryos and the ability to do pre Implantation Genetic testing. And they say, Oh, well, we thought you just put a bunch of embryos back and see what sticks. And we thought the success rates is like 20%. Again, when they were in medical school, 20 or 30 years ago, yeah, maybe it was when IVF first started. But now with all the improvements we've made in the lab, and growing embryos out to blastocyst and single embryo transfer, we actually put together a whole presentation to educate them on one of the big risks that insurance companies have is multiple births. So they're gonna pay up front and reimburse you for an IVF procedure. But the back end risk to them is if you have a twin or a triplet, they're paying $150,000 in NICU costs for a twin 500,000 or more for a triplet. And that's really where the risk is to them. So what we've tried to do is position ourselves by saying, We offer more than 90% 95%, I think of our patients get a single embryo transfer. I actually calculated our twin rate and our triplet rate based on our start. So it's published information on SART and showed the insurance companies why we actually were a better investment for them than some of our competing IVF centers because we represented a much lower risk. One practice actually had a $3 million multiple birth, Nicu cost risk based on their published SAR data. And we add 750,000 per 100 patients. So I said to the insurance company, look, we should be getting higher reimbursement. Because we're our our success rates are good, maybe better and but to you are Singleton's that's what's important to an insurance coming to you whenever healthy single baby twins and triplets is actually it's not a good outcome for patients. Some patients think it is. But it's definitely not a good outcome for an insurance company.
Griffin Jones 32:17
I'm kind of mixing topics here. But in a article that one of our journalists wrote a few weeks ago is about the genetics testing labs, and some of those companies closing their Rei divisions. And one of the reasons had to do with a lack of insurance reimbursement. And I remember reading it one of the sources said that insurance companies aren't motivated to reimburse necessarily because they aren't the same insurance company that is covering the obstetrics. And they're so if there is a multiple birth, that well, it's not. It's not the same plan. It's not even the same company. So but it sounds like what you're saying is it is enough to motivate people. Where how often is it the same insurance company versus how often do they see it as somebody else's problem?
David Stern 33:07
PGT A, is not generally covered by insurance companies. And I think they still believe and I guess you could argue and that's probably a topic for another podcast, you could argue whether PG ta makes a difference for patients or not in outcomes. I think some people argue for older patients, it definitely makes a difference. For younger patients, it's probably questionable. But insurance companies typically don't pay for that the employer benefit carve outs usually do. But it's a really interesting dynamic to and I answer your question first, and then I'll tell you the kind of the interesting dynamic for doing IVF because the patient is doing IVF and then having the baby nine months later, after they start IVF maybe a year later, there's not as much switching thing the switching occurs if someone's freezing, usually in two years, if they have frozen embryos coming back, then maybe they had started with a different insurance company. People change insurances, you know, every year or two employers will change insurance companies. But I think in the course of an IVF and delivery, it's pretty close enough that for the majority of the insurance companies, if they're paying for an IVF, they're most likely going to be paying for that upset. Typical outcome. The P egta. Though what's really interesting and again, really illogical, is Massachusetts typically does not cover for pgti. If you're a Blue Cross Blue Shield, Harvard tufts united. So a patient has depending on their insurance plan, maybe three cycles of IVF covered or six cycles IVF covered, but not pgti. And that's an out of pocket expense. So an insurance company, you do IVF they will not pay for your embryos to be tested. That's an out of pocket expense for a patient which could be three or $4,000 of additional cost, but they will pay for those subsequent frozen embryo transfer. Have untested embryos and subsequent IVF cycles. So we have patients that say, I have a small copay for IVF. For my frozen embryo transfers, I have to pay $3,000. For pcta. When IVF is covered, I don't want to pay for the testing, I'll just go through another cycle if I have to, because that'll be paid for. So it's almost this strange when I say illogical, because the insurance company would rather pay for a whole nother IVF cycle with all the frozen embryo transfer cycles associated with it. Then to pay a contracted rate, they wouldn't give us three or $4,000. If that's our self pay rate, they would pay a contracted rate for PG TA and the insurance companies don't do that. So there
Griffin Jones 35:45
are times where they're outdated information or their lack of completeness and what they're reimbursing for hurts them to.
David Stern 35:54
I think you could make the argument that economically it hurts them. They make the argument that in insurance, it's very slow. For example, egg freezing, some states have egg freezing as part of the fertility mandate. Massachusetts does not there's actually a bill before the Massachusetts legislature to include egg freezing cryopreservation for cancer patients. But today that's not covered. That's not a pocket expense. And I think the reason is that insurance companies still see even though ASRM lifted the experimental nomenclature probably 10 years ago at this point, they still see it as experimental. And they see PGA is experimental. I want
Griffin Jones 36:33
to talk more about positioning to insurance companies. But back to the audit. There's something that's still stuck in my mind, which is how does a fertility clinic even know what they could bill for? Does a an insurance company have to give them all of the possible codes that they could look into? Like I'm thinking of if you had an inexperienced billing team, they might not even know that there's a transvaginal scan that they could be billing for that, which is why they're only submitting for the abdominal scan? How do they know what's out there?
David Stern 37:06
I think from a billing standpoint, CPT codes are pretty much is so CP na CPT 10 codes are? They're published and the CPT reimbursement is generally based on Medicare, Medicaid. So the Centers for Medicare Medicaid, CMS, RCM is published publishes here are the different CPT codes. And here's the standard billing. But the fact is we don't see Medicare or Medicaid patients. So oftentimes what they try to do is they say, Okay, well, this is the closest CPT code to what we're doing. And so we're, that's what they're billing for. There is actually egg aspiration as a CPT code, embryo transfer as a CPT code. So there are fertility specific CPT codes.
Griffin Jones 37:50
You talked a bit too about how the customer service has suffered since COVID. And that was actually a question someone asked me to ask you. So I'm gonna get better at getting questions ahead of time from the audience, because I get all kinds of Monday morning, quarterbacks, David, and I love my Monday morning, quarterbacks I love when they email me and say you should have asked this, you should have asked that. It's like, Well, okay, I've got that for next time. I think we will have something where I get questions ahead of time. But there was someone that I knew that was struggling a couple of people that were struggling with their insurance companies. And so I said, Well, I'm going to be talking to David Stern about this, what do you want me to ask him and they one of those people wanted to know, if you had any advice for how you get a dedicated rep, if you're a smaller practice, because this person said the same thing that especially since COVID, they they can almost never get the same person on the phone or a person on the phone at all. Do you have any advice for how practices get a dedicated rep?
David Stern 38:49
Unfortunately, I don't. And we don't have dedicated reps, we're dealing with 1000s, like literally 1000s of patients with our local insurance companies. And we don't and in fact, we've asked for that as well from our insurance company. And that one example I gave you, and I think insurance companies look at this, you know, their businesses. Infertility is a very, very small segment. Even in a state like Massachusetts or Illinois, we're still a drop in the bucket for an insurance company that has millions of lives, and their prior authorizations. You have to get prior authorized for any elective surgery, any procedure. And there's so many things that insurance companies now put the onus on patients to get approved before they pay for it, that you can probably imagine the amount of approval and paperwork that's has just been elevated so much that they can't have one person that just deals with fertility. I'd be nice. We've asked them for that. But unfortunately, that's not reality at this point,
Griffin Jones 39:48
even in Massachusetts, even with a group the size of Boston IVF.
David Stern 39:51
Even in Massachusetts, I don't think the size of the of the center matters because in the Boston area, we have five or six IVF centers is all working with Blue Cross patients and Tufts patients and Cigna, you know, united? I mean, and between all of the IVF centers in Massachusetts, I'm sure we're talking about 2520 to 25,000 cycles a year. But there aren't any dedicated. Not that I'm aware of,
Griffin Jones 40:22
how much does the tactics of making the case for reimbursement change depending on what your market share is, and depending on how big your group is, so you talked about when you made the case, for when you were only getting reimbursed, maybe 50 50%, of what a cash pay patient would have been able to pay. And you were almost at a point where you were at a point where you couldn't afford to be in that market. It sounds like you made that case for reimbursement increase successfully. But how much does it vary. When you're in a place like Boston or New England where you might have more than half of the market share, you've got you've got so many Doc's that if they didn't do that, they would be really in a bind with it, the employers that they're contracted with, because now all of a sudden, my employees can't go to the majority of the docks in this area versus when you're in a market where you only have a couple docks, and there's several docks in the area. It's a game of chicken.
David Stern 41:20
And we it's we actually weren't successful, we went to three insurance companies in upstate New York, we were successful with one, the other two we were not successful with. And we said, Okay, we will not participate in your network anymore. And unfortunately, and this is one of the things that I think is frustrating. And you have a state mandate, but you're in a geographic area. So you're in Buffalo, there's a handful of IVF went through IVF centers in Buffalo. So we we're in, we're not in Buffalo, but we're in Syracuse, and we're on Albany, and the closest in network for one of these insurance companies is Westchester, or Rochester, which is a two and a half to three hour drive for patients. To me, this is a major area of concern for access for the state, the state has said we think patients should have infertility coverage. But yet the insurance company is not going to be paying the senator, what we feel is a reasonable rate. And it's not just us saying it's not reasonable, we're comparing it to other payers. And so in two situations, we said, we're not going to continue with your network, the third one agreed to increase and gave us a 67% increase in our reimbursement rate. And I said to them, Hey, we're also negotiating, and we're walking away from these other insured regional insurance plans, you should go after their employers, you should go to their employers and say, we have a network Boston IVF. And this other company that you may be insured with just dropped them. So it's a way to position maybe one insurance company against another one. But there's also another dynamic and one of the dynamics that you see where you have academic institutions, is they have a much bigger base for insurance. And they have much more leverage than an independent IVF center, Boston IVF. We've got an affiliation with Beth Israel, but we are an independent IVF center. So we probably don't get the best reimbursement that a Brigham and Women's or MassGeneral, which have their own hospital based IVF centers get. So even though we have a higher market share, yes, we could say to one of our large payers, if you don't give us this increase, we're going to go out of network with you. And it's a question of, hey, if they're a very large payer, do you really want to do that? Because you're now risking these large volume of patients, as long as you're making some profit, and you have to decide individually, what's the right amount of profit? I think it's a balancing act. So we been able to go to our reimburse to our payers and say, we put a whole presentation together we said, here's the inflation. If inflation right now is six or 7%. And you have a 2% escalator in your contract. That doesn't make sense, right? So we've gone back to insurance companies and said, You have to give us a higher escalator because the market dynamics have changed the environment has changed our costs to hire nurses, embryologist physicians has gone up significantly. And we presented that data to them and we said since the pandemic, our our internal cost to run, the practice has increased almost 20% A 2% escalator just one cutter for us, and so we're able to negotiate with them to get a higher reimbursement rate.
Griffin Jones 44:58
So in the cases where where it is, it isn't even chicken in that, like you can't sort of way because the only place you can go into is a wall like in the case of upstate New York, when you're talking about the two groups that you walked away from, listen, we can't be in network with you. And you talked about a strategy for the third that did give you that 67% increases, hey, listen, you are the ones providing access these folks aren't and consider going after their employers. You're kind of passing that along to them. But I wonder if it does it make sense for some groups to build a relationship with the sales teams of the insurance companies, because that seems like it both in this particular instance, and perhaps some others that could give you some leverage?
David Stern 45:44
I think with a lot of the typical commercial realist regional plans, not as much, but absolutely for the employer carve outs, where you have an A, we do a lot of joint partnerships with, for example, a progeny where we'll have one of our physicians go into a progeny employer and do a fertility 101. For other employees, they'll video they'll do a webcast, they'll record it and make it available to their employees. And we think that's a great win win opportunity, because we've partnered with them as a carve out, and they want to let employees know that fertility is covered. And oftentimes, the employer that is hiring a progeny or a win is doing so to retain their employees, because they think that fertility is a good benefit to offer.
Griffin Jones 46:36
Were you talking about the example of Boston IVF, and maybe having to decide of, well, they could go to bring women's they could or they could go to another hospital system and, and kind of deciding based on the market share. And other factors, I had one person talk to me about what MSOs often say fertility networks often say, which is we can help negotiate better rates because we have more volume. And there's a for utility, Dr. Practice owner that I know very well in a major market that has a good sized group that everybody would love to buy. And so far this person hasn't sold. And I talked to this person about this particular issue. And this person said, Well, the way I see it is that it doesn't matter what scale they have nationally, it only matters the scale that they have in my marketplace, that if there's 40 docks here, and they they can have 50 docks nationwide. But if they only have three here out of the 40, here, they don't have any leverage with the insurance company in terms of being able to position for reimbursement increases. But if there's 40, Doc's here, and we have 16, in the entire metro, we have 20 in the entire metro, then we really have that that power. And so can you speak to that dynamic?
David Stern 48:01
I would disagree with that. And the reason I disagree with that is there have actually been situations for practices that we've acquired, that were not on insurance, and we've been able to get them on a national insurance in the center of excellence, or get better rates for them. Because it's like, you know, very myopic, you know, what you know, but you don't know what you don't know. And so from a rate standpoint, if we're getting a certain rate of reimbursement outside of their market, they don't know what it is. And I think this is one of the benefits that national plans can offer is if we're in different states, Ohio doesn't have a mandate, Utah doesn't have a mandate. But with we're on a UnitedHealthcare, or a progeny are one of these employers, that is not an insurance group that's national, we can maybe get them a better rate, because we know what we're getting paid. In the insurance mandated states. We know what's happening in that market. And we've got relationships with them. So I do think that there is an advantage there. I think the other thing, Griffin is, like I just talked about, I shared my insurance presentation with one of our network IVF centers. And so I've done all the work, I've done all the analyses, I've put this into a presentation. And all they have to do is at a local level put in their pricing. And all of it's already been done for them. So it's a value added service that I think we provide to our network partners, because we've done the work because we're living Boston IVF the mandate in Massachusetts been around since like 1988 or 1990. So we've lived in this world for a long time and know how to be more efficient. Maybe we know how to operate with the insurance companies and how to talk to them and speak their language and I think that is something that we probably have to offer that. That's why I would respectfully disagree with the opinion of that individual practice owner. saying, Well, what can these other networks provide me?
Griffin Jones 50:03
You talked about ownership of the same brand of insurance company being different in different states. They're almost completely different companies in some cases. But is there any kind of, and we're not talking about legality, but the equivalent of case law or precedent that if you've negotiated something with Blue Cross of Illinois, that when you're then talking to Blue Cross of New York, that you could say, Listen, this is what we went through with Blue Cross of Illinois. And this is what they did. And so do you do reference any kind of precedent? And how helpful is that? Each negotiation
David Stern 50:37
is a separate negotiation, and they have different models. One of the things that they often look at is, what is their regional differences? So the cost of living is something that obviously, you know, differs, if you're in upstate New York, or if you're in Boston, the cost of living is very different, will have we have different pricing as well, we don't have one network price across all of our locations. It's very much market dependent. So I think in that sense, you're going to negotiate based on your local market environment. But there are absolutely national ways of looking, I mean, single embryo transfer, PTA use cost of multiples, all of that doesn't matter where you live. So yeah, you could argue that while our NICU costs are a little bit cheaper, yeah, they're a little bit cheaper, it's still 20 times what it costs to deliver a single healthy baby, you can argue with that. So in that sense, there are definitely learnings that you can take from one market to another market. But it might be you know, different. I think a center of excellence model is probably more of a trend where again, this is something insurance companies haven't caught up with. When you look at a group like progeny, they have a center of excellence model, because what they do is they set standards, and when they're selling into an employer, they're basically selling standards if they don't control themselves, because they're going in and part of the big message that a progeny is saying to their employers is your self insured, we can help you protect the risk on the back end. So for them, they don't want to be going into a practice that's got a 35% Multiple birth rate, you know, or someone that's doing 15% single embryo transfers with a majority of the transfer has been double embryo transfers, because that's going to hurt progeny on the back end. And I don't know, you could ask someone from progeny, but maybe there's some kind of either incentive for them to have a high single birth rate or a disincentive for them on multiples, I wouldn't be surprised if that's an employer, kind of employee player benefit manager contract,
Griffin Jones 52:47
who sets the terms for the Center of Excellence designation, because I have heard a practice owner, not be happy about not being part of a center of excellence. And from that person's perspective, their group was left out that it was negotiated with the other group, and that it was deliberate, and there isn't really a clear path for them to be able to become a center of excellence.
David Stern 53:14
I think that's a big frustration for for centers. And again, being part of a national group allows you to go with more leverage to one of these car ballots and say, hey, they're part of our group. Can you put them in, but it's like anything else if you're in a in a crowded market, and there are six or seven IVF centers? It's, it's almost like a game of an employer, Carvel could come and say, here's a rate war, if you take a 20% discount in reimbursement, maybe you'll come into our network. And we'll work on you to improve the rates or work with you to improve the rates. I think typically speaking, each each carve out will set its own standards of what they would like. And we get report cards. I actually like that we get report cards every quarter to see where do we rank? What are our statistics, and then at a national within their network? How do we rank against the whole network? And I think it's a great benchmark for us to look and see where we're doing better, where we're doing worse. And, you know, we can we can look at that as a group and say, oh, you know what, most of them again, because we're in a managed environment, we're probably doing better than than most average.
Griffin Jones 54:33
I want to ask you about the employer carve outs and what that's like in negotiating with insurance companies versus companies who that's their main purpose. You mentioned something earlier when you said companies like Cigna are starting to do more of those carve outs and that made me think, why didn't they do that? More recently, I think about this often David, like how was progeny allowed by the Highmark Blue Cross is the Cigna as the Aetna as the United How was progeny allowed to even become a big publicly traded company? But like, it doesn't seem like they're I know, it's a small piece of all of the things that they do, but they're also not in the business of leaving money on the table, I don't think and it seems like they did. And that's how progeny and carrot and that part of kind body came to be. Why has it taken them so long?
David Stern 55:27
I think it's specialization. Infertility is very, it's a very specialized niche field, right. And so when you understand the field, and you see a basic need, and this is where, you know, progeny, carrot, you have innovation happening, and there was a need for it. And it was created. I was just at Reproductive Health Innovation Summit two weeks ago, and I was on a panel with David Sable. And David made a comment and said, oftentimes, innovation doesn't come from the large companies, because there's no incentive for them to innovate. It comes from disruptors. And this is a perfect example of a big insurance company saying why do I need to provide that? Like, yeah, if you want insurance coverage for infertility, I'll give you a plan that covers it. But there isn't that innovation, it's like, yeah, sure, we'll just pass on some of the costs. And here you go. And what progeny has done, what Karen has done with Maven, kind body, all of these have done is they've said, Well, there's a need for this. One of the things that they do well is they counsel the patient, when you have a patient that has just in a state mandate, right, one of our big local insurance United or Blue Cross the patient's drone into us 10 foot deep swimming pool, and they're thrown in and they're saying, hey, go swim. When they're with an employee benefit management group, they have a care coordinator. They're given counseling, they're helped walking through the process in a white glove type of manner. And the employer pays for it. But it's a much better patient experience than just like any insurance, you go to the doctor, the doctor says you need to have this done. And you're thrown in the same pool of anybody with infertility coverage, you got to figure it out, you got to call the specialist area network, RJ network, what's covered what's not covered, all of that, that's our insurance system. So the carve outs have done a really nice job. For those companies that say this is important. We're going to provide this white glove concierge service. And we're going to help you navigate those fertility waters in a much better way than a commercial insurance like a united does, or Blue Cross,
Griffin Jones 57:49
who you and Dr. Sabel are talking about here is the principle or the theory of disruptive innovation. It's the blockbuster Netflix dynamic. And I know that because I've referenced this book a couple of times I couldn't remember the author or the book, Dr. Eduardo Harrington sent it to me it's called How will you measure your life the author is Clayton M. Christensen, he's a Harvard MBA was a Harvard MBA that wrote the theory about disruptive innovation, what David and David sable are talking about, and I've left the book in my office now as opposed to down on my home bookshelf so that I can remember it. So I guess that satisfies me a little bit of how they you know, of how those big insurance companies have allowed that piece of their market to go. And I guess now that now they're responding that the disruption seems to have been begun up. So what's it like? What's the difference in negotiating between those, what we'll call carve out companies will compare benefits companies progeny carrot kind body versus negotiating with traditional insurance companies
David Stern 58:50
with the biggest advantage is that you're negotiating with someone that has knowledge about the field, and they can appreciate, you know, what benefit PGA may bring to some patients. Whereas when you're negotiating with one of the locals, they often are they're not an expert. The people you're negotiating with are business people. You're lucky if you have a medical director that's involved in the medical director oftentimes has no inclination of what infertility is today. They know it from when they were trained in medical school, many times they're not even OB GYN is one of the things you just said though, Griffin kind of reminds me of the Shark Tank, which I know you love watching. I love watching as well. But they're always you know, Mr. Waterfall always says, Oh, they're gonna squash you like a bug. But that's the whole point is these companies. There's a need in the market for it. And yes, there are large companies that could squash them as a bug and if they get big enough, maybe they will. But it's, they're like little nuts flying around for these big insurance companies. Infertility. If you think about if every patient in the United States there's 12% for infertility, the amount of we have 300,000 As an IVF cycle is happening, I'm sure the 2021 sar data will be higher than that, let's say it's 500,000 500,000 IVF cycles is still a pittance compared to what these insurance companies are dealing with on a day to day basis. So I think that's why we see until something works. And they're like, Oh, so this one large employer, Google, or Apple just carved out fertility benefits, and maybe that's something I could have, and maybe I could get more revenue from them by offering the benefit. It takes a while for them to figure that out.
Griffin Jones 1:00:34
Sometimes it has to be a big enough bug worth squashing, am I right? I think about Kevin O'Leary's analogy, sometimes I think of the old imperial model versus rebellions. Like if you think of the empires of the Mongol Empire, you have rebellions going on in every little town in every little kingdom, fiefdom, or at least the opportunity to and you can squash up Genghis Khan can go with his whole army, and obliterate that rebellion. And very often he did, but he can't dedicate to every single one. In fact, when rebellions were successful, it was usually because he was off squashing some other rebellion. And same can be true for these companies, too, is that there's probably infinite opportunity costs that they could be pursuing. And so they're, it's about prioritization.
David Stern 1:01:25
And what you see in the insurance field today, which I think is very interesting is they're going on buying primary care offices, and they're buying specialty practices, and they're combining them. Because I think what they feel is that's more of a priority for them to save money is to control the costs on that end, in primary care, or cardiovascular, these very large areas of risk for them. And infertility is still a very, very small area of risk for them.
Griffin Jones 1:01:50
Another practice owner wanted to know, what do you do when the employer benefits companies come in strong, especially if they're new, they might come in a bit stronger, they've just raised a lot of capital, they're not so worried about particular profitability, or they think that they'll scale but then they slash reimbursements in year two,
David Stern 1:02:10
I think it's like any insurance company as well, you always have to do a business analysis, and you have to say, is the benefit worth the downside? And so if they're coming in, they're slashing I think, in this market, honestly, where everybody's costs have gone up, where inflation is, you know, PERS, what, five 6%, higher than we're normally used to. I don't see how insurance companies, whether it's a carve out or anybody else can come and start slashing. I think that's the wrong model. Everybody's a business. You know, you mentioned progeny, there. They've been very successful. They're growing their revenues, they're reporting it. So you can see that if they've grown by a million additional employees in their group, and they're growing their revenue, how can they come and say, we're going to cut our reimbursement to you, when your costs have gone up. And they know nursing costs, embryology costs, physician costs, all of that has gone up, not to mention supplies. So I would, I would say, no matter what your market share is, I think you got to push back and you have to say, okay, maybe it's not worth it to be in that network. If you can't make what margin you want to make. You have to do analysis and analysis to say, is that business worth it to me, and if it's not worth it, then you walk, and you use your feet and say, I don't accept those terms. And you walk away and you make it up somewhere else, and you have a better margin, and you'll be better off from a business standpoint.
Griffin Jones 1:03:40
That's the advice that I've given people. But I want to know, if you think that it's bad advice, at least to the extent that I'm that I've given it and when I give it, David, it's with an asterix. This is not my core competency. And I'm kind of guessing. So I let people know that, but I've just give them something to think about, which is if you have an employer benefits company in your area, and only a handful of your patient base works for companies that they're contracted with, and you've got a big waitlist, and you're seeing lots of people, and they really are nickel and diming on certain procedures. And I have had clients and other people show in reimbursement comparisons. And again, not my field of expertise, but it's like wow, that is low. That's that's pennies on the dollar. And so I say if you're in that situation, and you've got the waitlist, you've got the market share, and there's such a small percentage of it, do what you say and be willing to walk away. Is it bad advice, though, if then that company does go on to sign 12 more employers in that area and three years down the line? We're talking they've got 40% of the market. My viewpoint has always been what well, then you just negotiate in the terms that you're in And then I don't think you're gonna get any, like loyalty points for having taken a really crappy deal now, but is there something that I'm being short sighted about what that advice?
David Stern 1:05:10
I would say that's probably good advice. One of the things that you mentioned which, you know, every every practice has a different dynamic, but if you have a waitlist, and you know that you've got patient a man, you don't know what that's gonna look like in a year two, three from now, who knows? Right? But none of us do. We don't have a crystal ball. But if you have those patients, I would say, it's better to take those patients and give them the best patient experience and hire an additional nurse, or, you know, hire an additional person to answer phone calls or answer questions and forego that contract. If you can't get the reimbursement you need. Take care of the customers you have, or the potential customers when you have a waitlist. I mean, that's a great situation to be in. So to say, we're going to now add additional patients into the waitlist and have less, less margin to do it. So we're going to skip because we can't hire the people we need to hire, then it's not a good situation for anybody in your actual I don't know that your results will suffer. Maybe if you can't hire an extra embryologist it will, but the patient experience is going to suffer. And in the long run that might harm you more than not taking that contract. We have covered
Griffin Jones 1:06:19
a lot of ground today. How would you like to conclude about what clinics need to know or what they need to make payers know in the in clinics relationship with payers.
David Stern 1:06:30
Griffin, I appreciate you having me back on. It's always a pleasure to talk to you and the time flies by I think first and foremost a physician who is running or owns an IVF practice and to think about it. You are a physician you're giving care. You want to help people have children and build families. But you also have to understand it's a business. And you have to understand and identify where are your margins in the business. And we've seen practices across the country. Some of them have fantastic margins, some of them have not good margins. You got to understand what are your expenses? Where's your money coming in? Where is it going out? At at the end of the day? What helped us was one of the first things I did when I came in as CEO is I'm out I met with our CFO and I said I want to know all of our reimbursements by insurance contract, because I want to understand who's paying us well who's not paying us well. What is it cost for us to deliver care to one patient and that was the first thing I said, very high level a patient comes in. Here's how much nursing time physician time embryology time, here's our costs to deliver care for an IVF cycle and IUI cycle Clomiphene timing intercourse, I want to know what my cost is. And then we can evaluate where we're getting reimbursed. So it's no different than any other business. If you don't know what it costs you to deliver care. That's where you can really get in trouble. And if you wait until your accountant provides the numbers of the end of the year, you could either be really happy or really set.
Griffin Jones 1:08:09
The Time does fly by David. But don't worry, the Monday morning quarterbacks will give me plenty more topics for us to have an excuse to bring you on a third time and I look forward to when we do David Stern CEO of Boston IVF. Thank you very much for coming back on the inside reproductive health podcast. Thanks, Griffin.
Sponsor 1:08:26
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