Health Insurance Claim DENIED

[Anne2345]

Next week I have an appointment with a doctor to begin HRT.

Playing by the rules, and as required by my health insurer, I submitted a request for pre-authorization of medical services for coverage early last week with my health insurance provider.

After several discussions with the “case manager nurse” assigned to me, my insurer ultimately denied my request.

Specifically, my insurer cited the following exclusion within its policy:

“Some services are not covered . . . regardless of medical necessity. The following services are not covered:
. . .
Sex transformation operations and associated services and expenses.”

In other words, my insurance provider has taken the position that it will take an entire subgroup of the population, and sweep them under the carpet as if we do not exist.

As if this is not offensive and egregious in and of itself, my insurance provider even goes so far as to completely turn its back on me by stating it will not cover any such services “regardless of medical necessity.”

WHAT THE ****??!!! Are you kidding me??!!

I mean, I am a healthy person. For the most part, I take care of myself. I play sports. I’m active. I run five to six miles almost every single day. My blood pressure is good, I am not overweight, I stay away from fast food, I eat relatively well, and I supplement with daily vitamins.

Joe Blow down the street, though, is grossly obese, doesn’t exercise, is a total coach potato, chain smokes, and eats a double bacon whopper with jumbo cheese fries five days a week for lunch during work. The ******* also washes lunch down with a barrel of Mountain Dew. After work, Joe comes home, picks up the phone, orders a pizza, and drinks a twelve pack of beer every night while watching old re-runs of the Jerry Springer show.

Unlike Joe, however, I need HRT. I will lose my f'ing mind if I do not have it. I will die inside. My status quo is unsustainable. Gender dysphoria will eventually destroy me if I am unable to progress forward. I am transsexual through no fault of my own. Both my gender therapist and doctor agree that HRT is medically necessary for my survival and well-being, yet my insurance provider will not cover the cost of my treatment.

Joe Blow, on the other hand, is a complete and total worthless douchebag. Joe knows he leads an unhealthy lifestyle, but could care less. As a result, Joe chooses to do absolutely nothing about it. After years and years and years of abusing his body and health, Joe is diagnosed with heart disease. Heart disease will eventually destroy Joe if it goes untreated. My insurance provider, who also happens to be Joe’s provider, picks up the tab with no questions asked.

So I gotta ask the question again – WHAT THE ****??!!!

This is simply not fair. It is not right. It is complete and total bullshit. It is outright discrimination. And I hope the *******s rot.

Do not worry, though. I remain undeterred, and this changes nothing. Except for the costs I will incur. :doh:

[Danika140]

It's pretty discouraging to pay all that money for health insurance for something that may or may not happen in terms of medical necessity. Yet, when there is a medical necessity, an insurance company gets to decide to deny you the treatment you need, with the money you've been paying them.

[LeaP]

This reminds me of an old joke:

A guy catches pneumonia in a storm and is denied coverage.

"We don't cover flood issues, says the insurance company."
He breaks a leg at a neighbors house.

"That's the homeowner's problem."
His dog bites him.

"You need an umbrella policy for that."
So the guys finally asks his agent what is my insurance good for if it doesn't cover anything??? And the well-trained agent says:

"Peace of mind, friend, peace of mind!"

[Sandra1746]

If you can get the necessary prescriptions Estradiol patches and tablets are pretty economical. Not having your health insurance pay for it, especially after you paid into the pool is unfair but HRT won't break your bank. Surgery is however a different matter.

Been there, done that,
Sandra1746

[Amanda22]

You'll get it reviewed and approved, Anne. I have a really strong feeling this will happen. Lucky you!

[AllieSF]

I don't remember where you live Anne, but as ReneeT once pointed out, here in the USA it is not necessarily the insurance company that may have limited the coverage. If you have insurance by means of a "Group", i.e. through the company you work for or maybe some association that provides "group" coverage, it is probably the level of coverage selected and decided upon by that specific company or association. The insurance companies just provide a smörgåsbord of coverage options and if a "Group" is willing to pay for it, including the employee's contribution, if any, then that service would be covered. If you pay for insurance independently outside of a "Group" then you have to find a specific policy and company that may offer it. It will probably be more expensive then the base policies offered to most people. I know it sucks, but so far as I know, most companies do not include that in their coverage for their employees. It is changing, albeit slowly.

[melissaK]

Pretty impressive rant sweetie!

[Barbara Ella]

I know it is going to happen for you Anne. their reason is loopholed a bit, and should more specifically be directed to relief of gender dysphoria, and not sex change. I know where you are really headed, but for now your mental health is the prime issue i think. Not a lawyer, and do not know your policy, but your nurse did a very limited presentation of your situation IMHO.

Persevere dear, you have come this far.

Barbara

[MonctonGirl]

I agree with the insurance company - if they can prove that this was their policy SPECIFICALLY INDICATED on the documents you signed prior to actually paying them.

Might be worth having a friend PRETEND to seek insurance coverage from that company (same policy type )
and request their WRITTEN materials indicating what is / is not covered as of the date of their request.

...in case they are just making it up as they go along.

Insurance companies would never profit if they did not deny half of their legit claims.
They never WANT TO pay.

[Rianna Humble]

If you pay for insurance independently outside of a "Group" then you have to find a specific policy and company that may offer it. It will probably be more expensive then the base policies offered to most people. I know it sucks, but so far as I know, most companies do not include that in their coverage for their employees. It is changing, albeit slowly.

If you do change insurers, make sure that they will cover you for pre-existing conditions.

[Bree-asaurus]

Insurance companies care about their bottom line. They ACTIVELY seek out ways to not cover their customers. They have entire divisions dedicated to finding ways to deny people who have been paying them for YEARS.

I hate to be 'that guy' and tell you to give up... but... until our government starts giving us the protections we deserve, we don't have a chance against the insurance companies.

I've yet to even inform my insurance company that I'm trans or that I've changed my name/gender legally. They could drop me anytime they wanted and I don't want to give them a reason... (I pay out of my pocket... not through an employer)

[Persephone]

Bummer! Although the meds like Estradiol are pretty cheap, probably below any copay you may have.

A) Allie is right.

B) Did you read the poicy or terms of coverage before you signed up?

Hugs,
Persephone.

[Bree-asaurus]

I don't remember where you live Anne, but as ReneeT once pointed out, here in the USA it is not necessarily the insurance company that may have limited the coverage. If you have insurance by means of a "Group", i.e. through the company you work for or maybe some association that provides "group" coverage, it is probably the level of coverage selected and decided upon by that specific company or association. The insurance companies just provide a smörgåsbord of coverage options and if a "Group" is willing to pay for it, including the employee's contribution, if any, then that service would be covered. If you pay for insurance independently outside of a "Group" then you have to find a specific policy and company that may offer it. It will probably be more expensive then the base policies offered to most people. I know it sucks, but so far as I know, most companies do not include that in their coverage for their employees. It is changing, albeit slowly.

Well... most insurance providers don't include that coverage unless a company specifically asks for it. The option is there with some providers... but it only ever gets used if a company explicitly states they want that coverage. The company doesn't deserve any more blame than the insurance provider. In fact, the companies that DO offer transgender coverage through their insurance should be applauded for doing what's right.

If you do know of any insurance companies that provide coverage for us and our medical needs, PLEASE share!

EDIT: I think I just said the same thing you did with different wording... oh well... I'm tired...

[kimdl93]

Anne, I don't have any experience in seeking HRT coverage, but I know that generally speaking our insurance industry will deny claims until you put up a stink. Persistence seems to be the key. I'll give you two recent examples. My niece needed a procedure...I won't go into details, but her parents got the preapproval, scheduled a trip to Mayo clinic and just hours before the minor surgery was to take place, they wore informed that it had been "denied". Surgery was canceled...they reapplied and it was approved. NOTHING changes.

The son of a friend/co worker broke his arm in football practice. Our insurance plan initially rejected the ED claim because "it had not been pre-approve" Not sure how one gets pre approval on a broken arm. My friend's wife spent eight full hours on the phone arguing with the claims dept. But she eventually prevailed.

My advice is to not take the first denial as the final word. Push back. You're uniquely equipped to do so.

[Kaitlyn Michele]

fwiw...my insurance did not cover HRT...

you want to hear a kick in the teeth...

at my old company, starting in 2012 SRS was covered by insurance..

[I Am Paula]

After last weeks descision to re label GID, most insurance companies, and some countries socialized medicine, are dropping transgender care, as it is no longer a disease or disability. We won the battle for our self esteem, and lost the war. Be prepared for lots of denied claims, the descision will save the insurance companies millions.-Celeste

[arbon]

After last weeks descision to re label GID, most insurance companies, and some countries socialized medicine, are dropping transgender care, as it is no longer a disease or disability.

Hi Celeste - can you provide links to where you got this information?

[I Am Paula]

Just about every news cast about the GID re label brought the subject up. I watch the news, so, sorry, no link. Try going back a few days on major news sites. And I apologize, I should have prefaced the post with 'I heard', as it is for the most part unsubstantiated. Please, let's all keep an ear open for solid, legit news.-Celeste

I only had a minute or two, but I found one on a google search. can't vouch for it's legitimacy.

http://www.slate.com/articles/health_and_science/medical_examiner/2012/12/dsm_revision_and_sexual_identity_gender_identity_d isorder_replaced_by_gender.html?fb_action_ids=1015 1355004909808&fb_action_types=og.likes&fb_ref=sm_fb_like_toolbar&fb_source=other_multiline&action_object_map=%7B%2210151355004909808%22%3A450 715211643635%7D&action_type_map=%7B%2210151355004909808%22%3A%22og .likes%22%7D&action_ref_map=%7B%2210151355004909808%22%3A%22sm_ fb_like_toolbar%22%7D

[Jorja]

For future reference, I have always allowed the Doctors office staff make any medical request to my insurance company. They know the proper language and coding to be used if the doctor wants to get paid. There are some things that insurance won't cover. However, if coded properly many things will be paid for.

[Lorileah]

Would it help if you thought of your insurance company as being named "The Sands" or "The Sahara" or "The Golden Nugget"? Because that is exactly what insurance companies are, they are gambling institutions. They make the rules they stack the odds in their favor. They also have the right to quit allowing you to play at their table if they think you may win. They have Odds makers (they call then actuaries), they have dealers and they have pit bosses. They don't have the ugly carpet on the floor and you don't get the excitement of maybe winning the big one. They do pay out small amounts on occasion just to make you believe that you have the chance of winning. But they hold the cards. That is why 5 of the top 10 financial institutions in the US are insurance companies. It is also why they are aggressively fight against government controlled health care.

In your case you walked into the casino with an ace (pre-existing condition would fit also), they know that a 10 will come up most likely and they will have to pay out Blackjack. So instead of letting you sit at the table, they just say the game is closed. And if you tell them you will go to another casino, they will be thrilled because they have the money you already paid.

[Nicole Erin]

Insurance companies are crooks. That is why on TV all the time they have attorneys saying they fight insurance companies.

Part of why it is hard for legitimate problems to get covered is cause of Joe Blow and others who abuse the system.

Well like Joe Blow.
Anne, the only falsehood in your post is - Joe Blow most likely doesn't have a job. He is on convalescence cause of a work related injury. Get it right.

[ReineD]

After years and years and years of abusing his body and health, Joe is diagnosed with heart disease. Heart disease will eventually destroy Joe if it goes untreated. My insurance provider, who also happens to be Joe’s provider, picks up the tab with no questions asked.

I am hoping this will change, to afford better health care for all of us. Recently I read a story from someone whose doctor refused to continue treating him if he did not follow doctor's orders for weight loss and blood pressure reduction. This was the first I had heard of this, but it makes sense, in extreme cases such as you describe with your neighbor. I also have a friend who is a CFO for a medical group. He was describing proposed changes in health insurance policies, where people who smoke, or whose weights indicate they are not following a healthy lifestyle, will be charged a premium for their health insurance. I don't know how they will differenciate between people who eat well and exercise and are still overweight vs. people whose high cholesterol and weight are caused by making poor choices, but if they are successful it will force people like your neighbor to make better choices, which will help to ease claims for medical conditions which are preventable.

I also think it is only a matter of time until gender dysphoria becomes universally acknowledged as a medical condition that needs to be addressed.

[ameliabee]

Don't have it billed as part of 'sex reassignment'. As Jorja said, HRT docs and their staff know what they're doing; officially, I'm not transsexual or gender dysphoric, I just have unspecified endocrine and anxiety disorders.

[Dawn cd]

Progress is being made on some fronts. Here is a story from The Gothamist, a local NYC newspaper:

In the old days when someone wanted to pay for a sex change operation they just robbed a bank. But now insurance companies are paying for procedure, at least in the case of Queens resident Ida Hammer, whose insurance company has finally agreed to pay for her male-to-female genital reassignment surgery.

MVP Health Care at first balked at paying for Hammer's surgery, arguing that it was "not medically necessary" and fell into the "cosmetic surgery" exclusion in their plan. But Hammer was determined, and enlisted the help of the Transgender Legal Defense & Education Fund, which successfully argued that Hammer's "Gender Identity Disorder" is characterized by the AM as a "serious medical condition" that if left untreated "can result in clinically significant psychological distress, dysfunction, debilitating depression, and, for some people without access to appropriate medical care and treatment, death."

After denying two appeals, MVP reversed its decision and will provide full coverage for the procedure, which usually costs around $20,000 not including follow-ups and therapy. "My insurance company should not be second-guessing my doctors," says a victorious Hammer. "I’m relieved that it is finally treating me fairly and covering the health care I need."

Here is the link:
http://gothamist.com/2012/10/04/transgender_woman_gets_health_insur.php

[stefan37]

Anne,

My insurance company also will not pay for my estrogen. They will pick up my spiro and syringes. I have to pay out of pocket for my endocrinologist as he is out of network. My blood work is covered. I have to say if this is getting you worked up you are in for a long haul. Facial hair removal is going to cost easily 10x the cost of meds and doctor appt and will take much longer than you think. Hopefully HRT will help alleviate the anxiety of GID and help you manage while you proceed down the path you choose. You will definitely need to develop patience as none of this happens overnight. From your previous posts you still have marital, work and socialization issues to work through. Worrying about the cost and monitoring of HRT therapy is non productive at best.

[LeaP]

The level of misinformation in this thread on insurance companies is staggering. I work for one of the largest insurance companies in the world. In a senior position. People are ethical, honest, and hard-working. Actuaries are statisticians modeling complex, scenario-based cash flows built on economic projections, sales projections, investment assumptions, interest rate projections, policy assumptions, demographic changes, and a host of other considerations – against equally complex projections on the output cash flow side of the product lines. Oddsmakers? Please. It takes longer to become a fully accredited senior actuary than it does to become a doctor.

There are no divisions of people looking to squeeze the poor policyholders. Most claims are processed automatically against the parameters of the plans, assuming they're coded properly to begin with. Exceptions are kicked out and handled manually. Guess where? In great big call-centers staffed by ordinary people. Because plan provisions vary by client company, customer service people try to figure each case out the best they can. And they do make mistakes. They are often in the same plans themselves. They are not trying to screw anyone.

The coding system is complex. It wasn't invented by the insurance companies! In the US, it was expanded enormously by the Clinton administration. The intent was laudable. It was to bring more precision and granularity into the coding, in turn to control costs more precisely. What actually happened was the volume of coding errors skyrocketed, along with claims resubmission and manual handling. Costs ballooned for both the insurance companies and the practitioners submitting claims. When my wife was a medical practice administrator, she saw some marginal practices leaving as much as 50% of their claims on the table because of errors and rejections and their inability to turn the resubmissions around. You haven't seen dysfunction until you've seen a clerk take a pile of claims in a surgery practice and toss them in the trash at the end of the week! The insurance companies at least track and disposition every claim.

Most insurance companies lose money on their insurance operations. There are several types. There are open market policies, for which the insurance companies ARE mostly responsible for the coverages. Even here, insurance is a highly regulated industry. All companies, policies, and processes are subject to government oversight. The other main type is the familiar large-company policy. These are for companies that are self insuring. In this case the insurance company provides a selection of policy frameworks, which may be further customized any way a client wishes, and then performs a servicing function for a fee. There are additional types also but that's close enough for this discussion.

Where do they make their money? Investments. Actuary derived flows are the liability side of the ledger, investments are the asset side of the ledger. The flows have to be matched by product line (at a minimum) to provide cash for claims as well as profit. Risk from a variety of sources has to be covered – whether hedged in the investment portfolios, by reinsurance, or by other means. Product profitability in the industry is a very difficult thing to manage.

In my opinion, the biggest barrier to transgender coverage isn't discrimination – it's a lack of data. If a client firm wants transgender coverage, they provide it. Period! It makes no difference whatsoever to the insurance company – because they're only providing a servicing function anyway. (Again, speaking of self-insured employer plans.). Neither the insurance firms nor the insurance companies have a base of actuarial-quality data on which to advise or make rational economic coverage decisions, however. The data perspectives put out by groups like the human rights campaign sound compelling, but they don't provide the precision required for large-scale product decisions. And friends, business decisions on the expense side of the ledger are not left to chance.

If morality plays in this, it's that the state is complicit in creating a system whereby it is no longer possible to get quality health care without being insured – unless you're rich. People need to give some consideration to the fact that that situation is relatively recent, however. (Since the 60s, more or less.) The current model is contract based, not rights based, its roots extending back to the 1500s and 1600s. The industry needs to evolve but is constrained by government in evolving.

And I don't have transgender coverage either. You would think I might … given that I'm a crook out to screw the population for my own benefit. Greedy corporate ******* and all that. Uh-huh.

[AllieSF]

Thanks for the "other" side of the story Lea. There always is the "other" side that a lot of people do not want to hear.

[darla_g]

good luck with dealing with your insurance company Anne

[RenneB]

On a slightly related note, regarding the obese couch potatoe, I have heard of one company that tests for nicotine and adjusts your participation costs accordingly to the actuarial rate for those patients that use tobaco products. I have also heard of another company that adjusts your health care costs based upon your BMI... As Lea said, it's whatever the company wants to cover.

I'd rather spend my time on identifying companies that are LGBT friendly and then supporting them and hopefully they'll get the message and provide coverage that covers the LGBT community.....

just my two cents .....

Renne.....

[Nicole Erin]

See one thing I do not get about insurance is this -
OK so day in and out they are paying for some couch potatoes' self-inflicted health problems, and there are a lot of people like that.
Just how many TS file for claims for transition related costs? I mean there are not THAT many of us.

I mean there is probably one TS out there for every 100 fat slobs sitting around collecting disability who cannot work cause they are overweight and have related health problems.

[Persephone]

Well said, Lea P! But you may be a voice of reasonableness shouting into a wind of dissapointment and frustration.

Hugs,
Persephone.

[elizabethamy]

Lea, thanks for the insurance industry perspective. The U.S. has truly built the most complex, expensive, and rickety health care system imaginable. Even while most people within it are doing their absolute best to be honorable and helpful. The incentives are all screwy. But in terms of transgender coverage, I think the exclusion is less a data issue than a moral one. If there's so little data, and so few people requesting the service, then why go out of your way to exclude it? I work for a liberal university that prides itself on all its groovy human rights, HR policies, and even now offers dorm floors that are not gender-identified (meaning, really, a haven for transgender or trans-exploring students). We have a gigantic gender studies program and a host of research institutes, special library collections, art exhibits, etc, devoted to gender issues. But our insurance policy --which has very few explicit exclusions -- has a clause that "no services or procedures related to sex change shall be covered." My guess is that for the people who wrote this policy, it's a moral stance, probably more unexamined than repugnant, but the effect is the same. And even though I have not yet (and may never) sought these "sex change" services, just seeing this exclusion in the policy summary is a direct affront to who I am every day while I work on behalf of this institution.

So I think part of our civil rights struggle has to be to fight this extremely common policy exclusion, whatever its origin. I know that up until the surgical moment, sympathetic doctors can be artful coders on our behalf. But still....

elizabethamy

[Diana L]

Thanks for your response Lea. I have beenin the insurance field almost 35 years and the amount of anger towards us is very frustrating at times.

Diana L

[Anne2345]

Thanks for your response Lea.

Indeed.

Thank you, Lea. Your response was fair, informative, and educational.

It is sometimes easy to forget that there are two sides to every issue.

I got caught up in the emotions of the moment and the argument, without having a substantive grasp of the underlying facts and circumstances of how the industry operates.

It was not my intent to impugn or malign the character and reputation of an industry. Particularly one as complex and complicated as health insurance.

In particular, I hope that I have caused you no offense.

You know you are my sister, and I have nothing but love, respect, and admiration for you. I also trust you implicitly, which you know as well. :-)

So if I have caused any offense, please feel free to take a few pot-shots at my profession if that will make you feel any better. God knows my profession is an easy target . . . . :-P

[ReineD]

My guess is that for the people who wrote this policy, it's a moral stance, probably more unexamined than repugnant, but the effect is the same.

Or, because there is little data, maybe the cost/benefit ratio is too high? When your university looked at policy options, it may have determined that the higher premiums charged to everyone to include this did not warrant helping the small percentage who might want to transition?

Lea, two questions: would the cost of including trans related health care go up significantly for everyone and is this why most employers don't include it?

My second question has to do with the bureaucratic costs involved with all the coding errors, rejections, and resubmissions. Is it possible to simplify things in order to help practitioners get it right the first time and also, can you see any benefit to simplifying the coding, and could this be done easily in order to make health care more efficient? Also, in your estimate, how much of the bottom line does all of this red tape eat up?

[LeaP]

... The U.S. has truly built the most complex, expensive, and rickety health care system imaginable. Even while most people within it are doing their absolute best to be honorable and helpful. The incentives are all screwy. But in terms of transgender coverage, I think the exclusion is less a data issue than a moral one. If there's so little data, and so few people requesting the service, then why go out of your way to exclude it? I work for a liberal university that prides itself on all its groovy human rights, HR policies, and even now offers dorm floors that are not gender-identified (meaning, really, a haven for transgender or trans-exploring students). We have a gigantic gender studies program and a host of research institutes, special library collections, art exhibits, etc, devoted to gender issues. But our insurance policy --which has very few explicit exclusions -- has a clause that "no services or procedures related to sex change shall be covered." My guess is that for the people who wrote this policy, it's a moral stance, probably more unexamined than repugnant, but the effect is the same. And even though I have not yet (and may never) sought these "sex change" services, just seeing this exclusion in the policy summary is a direct affront to who I am every day while I work on behalf of this institution.

So I think part of our civil rights struggle has to be to fight this extremely common policy exclusion, whatever its origin. I know that up until the surgical moment, sympathetic doctors can be artful coders on our behalf. But still....

elizabethamy

Your university sponsors the package - not the insurance company. They reviewed and approved the exclusion, and may have requested it. Most major universities are self-insured besides.

I think your complaint lies with the proud, liberal university with the big gender studies program.

Core administration functions in universities don't always track to the public posture of the institution.

[melissaK]

Anne sweetie, what is your profession?

[Anne2345]

Anne sweetie, what is your profession?

I'm an . . I'm an . . .

OMG, this is soooooo hard. This is tough. I am soooo embarrassed and ashamed!!!

I mean, you all will not understand! You'll be horrified!! I'll be rejected and cast aside!!

But it's the truth!!! It's who I am, as terrible as it is!!!

I'm an . . . an . . an attorney!!! There!! I said it!!!

So let the insults fly, and commence the public stoning at your convenience!!

OMG!! I need help . . . I need serious help . . .

I am the lowest of the low. Even lower than insurance folk such as Lea!!! :eek:

Someone . . . anyone . . . please?

I am so alone, so afraid, so lost . . . .

How can this be??!! How can this be, I say?!!!!!

NOOOOOOOOOOOO!!!!!!!!!! :wall:

[LeaP]

In particular, I hope that I have caused you no offense.
...

So if I have caused any offense, please feel free to take a few pot-shots at my profession if that will make you feel any better. God knows my profession is an easy target . . . . :-P

Well, that's the thing, Anne, isn't it? It's way too easy! Because everything they say about lawyers is true! Wait… Was that a pot shot?? :idontknow: Hmmmm - Let me ask you directly: if it's true, is it a pot shot?…… Oh… Wait… You're a lawyer… You don't understand truth ... :kickbutt:

Nope. Not offended. We're cool! :cool::cool:



Lea, two questions: would the cost of including trans related health care go up significantly for everyone and is this why most employers don't include it?

My second question has to do with the bureaucratic costs involved with all the coding errors, rejections, and resubmissions. Is it possible to simplify things in order to help practitioners get it right the first time and also, can you see any benefit to simplifying the coding, and could this be done easily in order to make health care more efficient? Also, in your estimate, how much of the bottom line does all of this red tape eat up?

I drew a pretty hard-line distinction between "actuarial quality data" and other data perspectives. Just because there might not be good enough data for product profitability decisions doesn't mean there isn't sufficient data to give a rough idea of cost or feasibility, however. The little I've read suggests that, in the context of a large sponsor's plan, transgender benefits would likely be a drop in the bucket.

Anecdotal data from San Francisco shows only a small handful of transsexual surgery claims, for example. The assumption – and it's just that – is that the San Francisco employee base is likely to contain a higher percentage of transsexuals that might be found in a typical company. Further, that because of that, this experience can be extended to expectations for other companies.

Additional, corresponding assumptions – again, just that – is that other coverage items are either being handled already under non gender diagnosis-related codes, or that allowing treatment for related conditions (like gender therapy) would decrease costs for co-morbid condition treatment by reducing their incidence.

Outside of the trans community, there's a perception that transgender treatment costs are astronomical. They're not. The cost of something like SRS, compared against other surgeries is not very dramatic. Gallbladder removal surgery in this area, for example, bills an insurer approximately $10,000, and it's one of the simpler, more common procedures out there. Many procedures cost many times that. SRS costs less than the majority of them, by far.

It doesn't matter to most people what the billing cost is when they are insured. If it's covered, it's covered. There may or may not be a co-pay. There may or may not be a differential or deductible they have to pay.

What's more interesting to me is that it may provide a very clear case of market distortions when it becomes widely covered (as I think it will). In order to preserve a reasonable payback to the provider, billing rates will go up. The same provider who provides SRS on a cash payment basis for, say, $15,000 may have to bill an insurance plan $25,000… only to receive $8,000 or $10,000 from the insurance company.

As pressure increases to push down payback to providers over time, I would expect fewer providers in relationship to demand. That is, if coverage becomes more widely available, there may be more surgeons providing SRS – but because payback rates are relatively low, demand will outstrip supply. It's the same stuff we've been reading about for years. It's just that we don't get to see something enter into a mature system like this very often.

Think you'll be able to get SRS for that $15,000 cash any longer if you don't have insurance? Think again. Depending on the state and plan, a surgeon might not be allowed to offer the surgery for less than the insurance billing rate! All regulated industries produce market distortions. Some are good for consumers others are not. The people who really get it in the neck in this case are the uninsured.

God only knows what Medicare will introduce into the mix. One thing is for sure – it will further complicate reimbursement rates.

On your question of coding and simplification, I have some perspective but I don't have any hard answers on costs. I work on the investment side of the house, although I've written asset-liability matching systems and regulatory reporting systems, among others, for insurance companies.

It seems logical that it would be cheaper to go back to a simpler coding system. While it arguably overpays providers for some variations of procedures and underpays for others, I would think it would be a wash and error rates (and associated costs) would go down. But I actually don't really know.

What happens today is that the surgeon provides surgical notes and is supposed to provide the appropriate codes as well. The notes typically go to a coder who enters them into the insurer's system (or forms). The coder may be an employee of the practice or may be in a coding firm employed by the provider. The entry may be manual or may be automated at any one of several possible steps along the way.

Either way, there are old codes and new codes, codes and combinations of allowable "modifiers" that are recognized as legitimate. Procedures that can be performed together, and others that cannot. It's complicated, complicated, complicated. A good coder is worth their weight in gold. They can catch errors in the surgeons notes and codes at the source. They make fewer errors in entry. They know how to code a procedure for maximum reimbursement, and the reimbursement variation, depending on the coding, can vary enormously. Finally, they know how to work the resubmission process. Timeliness and accuracy are of the essence here, as it is not possible to resubmit a claim after certain amount of time. Things have changed from where you paid a doctor cash or you submitted your own claims to an insurance company, to now, where armies of coders have to be employed to run the process. There are dozens of specialty coder certifications for different areas of medicine.

Oh, then there's benefits coordination, clawbacks, and all kinds of other things going on behind the scenes between insurers, between insurers and sponsors, between insurers and regulators, etc.

I have no idea what percentage of costs all the process represents. But it has to be huge.

[Lorileah]

People are ethical, honest, and hard-working. Yes, most insurance agents, adjusters, and I am sure the rest are, just like in real life. I have known people intimately who were involved with the industry. My uncle wanted me to take over his very profitable agency. I just don't have the ability to sell certain things :) I respect your defending your profession.
Actuaries are statisticians modeling complex, scenario-based cash flows built on economic projections, sales projections, investment assumptions, interest rate projections, policy assumptions, demographic changes, and a host of other considerations – against equally complex projections on the output cash flow side of the product lines.
Change a few words and yes, you have an oddsmaker. They are statisticians, they weigh the risk factors, they project trends and probabilities, with the probability that they may lose on teh bet. They take the ones they expect will win, they refuse the ones that they expect will lose. Only major difference is one has the backing of large corporations :)

It takes longer to become a fully accredited senior actuary than it does to become a doctor. some doctors will tell you it takes a lifetime. (see I defend my profession also). There is internships, residencies, fellowships...so I will say it's a wash.


Exceptions are kicked out and handled manually. and since I was going with one of those people I can tell you that they do work hard. It isn't the claims adjusters or managers who are at fault. They have to work in the framework they are given. And recently, they are very over burdened and try to settle the claim as fast as possible, which often involves just taking everything literally. (and I hope this isn't YOUR ox, but the CEO and president of the company she worked for rode limos to work, had several houses and private jets, ate at fancy restaurants and lived in penthouses in New York...while laying off 75% of the labor force to make the bottom line look good, all without cutting any of their benefits.

The issue in this thread wasn't so much the fact that the coverage was denied. That is an issue of when the contract was written (read the fine print, right) but more the fact that the coverage was denied because someone, somewhere has made an independent decision that the treatment was unnecessary and dismissed, probably by your machines who have no emotion. Yes, I agree that the health insurance industry has created a monster, and ugly monster that is disliked by the policy holder (I had to pay a freaking 1200$ for a 5 mile ambulance ride for my wife to come HOME because after she was released from diagnostics and treatments, she was no longer a patient and they would not hospitalize her...two issues there 1200$ for an ambulance ride? ((Which BTW was the same bill she had going to the hospital...that the Ins co paid...250$...'splain that to me.))...and 1200$? for no support except oxygen? and you know those poor Paramedics didn't get 10%of that) and the doctors who have to take a 50% or more hit if they accept the insurance (how about we just set reasonable rates for everyone?). Hopefully, someday, we can all pay a reasonable amount that allows good coverage at a reasonable cost and it pays the doctor a good wage and it makes the Insurance company a reasonable profit.

Wouldn't that be lovely?

[LeaP]

Lorileah, one thing I've never defended is excessive senior executive pay. I believe that the "do whatever you want, it's a private business" bit stops at the doorsill of the small, family-owned, family-staffed and family-run business. Everything else runs under a framework of government defined structures and controls. The public is employed by such firms, and at some level executive pay has to be considered within the public interest, in my opinion. Another topic, though.

It doesn't matter how the rejection was generated. Emotion doesn't play into it. Emotion doesn't play when coverages are given, either. Just because your life-saving, open-heart surgery was covered doesn't mean there was some swooning clerk somewhere who decided you should be covered because you're worthy or something.


(Quoting Steve Job's here) ... "And one more thing"

The insurance company that provides my employer's plan is a nonprofit! Kind of puts a different spin on the corporate greed thing.

[melissaK]

It's who I am, as terrible as it is!!!
I'm an . . . an . . an attorney!!! There!! I said it!!!


I think ATTORNEYS ARE THE BEST PEOPLE. Smart, accomplished, dedicated; they provide all of society with the invaluable service of defusing the conflicts of their fellow humans in a civilized and fair system thereby preventing mayhem, and insurrection. Why society as we know it would likely totally collapse and all civilization would be lost if it were not but for noble souls such as you Anne!

I want to thank you for your service to us all Anne!!

Hugs,

'lissa, Esq. (since 1983)

[oh hey its anya]

Anne, is the 'case manager nurse' with the insurer? I know they do that sometimes...with a purpose of finding the lowest possible denominator for treatment.

Also if you have a specific clinic you are using, sometimes they have an insurance advocate on staff. See if they can talk to the insurer and work something out. They usually are more likely to fight for their patients. Sometimes it's a matter of 'the office' recoding it to something more urgent (hormonal imbalance? It's semantics...but...you have to play the insurers' game, which sucks).

Hang in there and stay strong (which you are doing!)

[Cheyenne Skye]

I have insurance through my job and I got their book about what is and isn't covered a couple of years ago. And of course, there was a specific exclusion to any trans related healthcare. So I too was concerned about how they would take everything from my therapy to doctor's visits, blood work and prescriptions. But thankfully I go to a provider that began as a clinic treating LGBT people for STDs and HIV. So my therapist bills my sessions as being for depressive episodes to the insurance. And my doctor prescribes my Spiro as being for my "endocrine disorder" and the Estrogen is "to help with my hormone status". So far, my insurance hasn't said anything about how everything is worded. I just pay my deductible and copay. So I'm good for now but if and when I want to do any surgery, it will have to come out of my pocket. I'm also not sure what would happen if I legally change my name either.

So like some others have said, see if they can word or code your treatment differently so you can get some things covered.

[Nicole Erin]

I'm an . . . an . . an attorney!!! There!! I said it!!!


OK fine you are an attorney... I have a question then -
Is it as fun as I imagine it to be when an attorney gets to stand up and yell "objection!" in court? Do lawyers ever get carried away with it like on Law and order where they break out in a yelling frenzy yelling it?

I always wanted to yell "Objection" in court but i don't think i am gonna be an attorney in this lifetime.

[mikiSJ]

Maybe we can finally get single payer insurance in our crazy country that will cover things like this.

If you were a Vet, you could have gone over to the VA, but not to Aetna!

[Cindi Johnson]

If morality plays in this, it's that the state is complicit in creating a system whereby it is no longer possible to get quality health care without being insured – unless you're rich. People need to give some consideration to the fact that that situation is relatively recent, however. (Since the 60s, more or less.) ... The industry needs to evolve but is constrained by government in evolving.


Lea, before you remove all blame for America's lousy healthcare system from the insurance companies and instead blame the government (i.e., the people who elect the government), allow me to point out that it is the insurance industry who have fought, for decades, the establishment of a single payer health care system in this country. Why? Because it would eliminate the need for the insurance companies. Canada and most European countries do just fine without health insurance companies.
Why are the health insurers one of the largest contributors to the GOP? Why do they hire hundreds of very well paid lobbyists? Why did they attack Bill and Hillary when Clinton tried to mandate universal coverage? Self-interest comes to mind; public interest does not.

[morgan51]

Yes welcome to transition american style! No support and huge bills and plenty of derision and pain. I'm even getting it on this forum today! Have a great day! M.

[LeaP]

Lea, before you remove all blame for America's lousy healthcare system from the insurance companies and instead blame the government (i.e., the people who elect the government), allow me to point out that it is the insurance industry who have fought, for decades, the establishment of a single payer health care system in this country. Why? Because it would eliminate the need for the insurance companies. Canada and most European countries do just fine without health insurance companies.
Why are the health insurers one of the largest contributors to the GOP? Why do they hire hundreds of very well paid lobbyists? Why did they attack Bill and Hillary when Clinton tried to mandate universal coverage? Self-interest comes to mind; public interest does not.

You are tilting at windmills. I said government was complicit. Complicit with whom? Insurance companies, providers, pharmaceutical companies, and their clients, medical device manufacturers, et al. It is a vast, complex system with MANY players. There's plenty of blame to spread around for the deficiencies of the system. I called out government because they are the ones who actually make the final decisions. They are the regulators.

Although people are taking it that way, I'm not defending the industry. My purpose was primarily to respond to the characterization of people who work in - and lead – the insurance companies as crooks and greedy, as well as correct some factual errors in the thread and provide some perspective. So I'm not going to respond to your other points, as they get into other issues.

Just two more points, though ...

Don't assume people's views on issues and politics from their putting facts on the table. My views are highly unlikely to be what you think they are. You might pick up a hint of that in my comments above on executive pay.

Regarding single payer approaches, regardless of any other merits, one concern I would have re: trans coverage is that if there is only one payer, there is also one denier. While I think the long-term trend is toward more coverage, a really radical administration (left or right) or a shift in the winds of public or medical opinion could literally eliminate such coverage overnight.

Which brings us full circle ... because then the only winners would be the d&%# LAWYERS! Anne, was that a pot shot? :daydreaming: