"Insurance" or "How much did I just screw up?"

[Raya]

(This is a US-centric post. Sorry. )

Hello again... Long time, no post.

In a nutshell, I'm wondering if I just handed my health insurance company the excuse they'd need to make my life a living hell. So here goes...

Lately, I've been busy getting my ducks in a row for HRT. Before I start, though, I want to store my sperm. I just had my first appointment, but the whole thing's been eating at me since.

When I first started out, I learned that a local university ran a cryopreservation facility through their OB/GYN program (the intake forms were...interesting).  I was all ready to go, but they had to go and inject reality into my dreams. Turns out, I need an initial consultation: the wait for those...six weeks. I called them up and we then talked about my insurance and my reasons for seeking them, to which I told the truth. I wasn't worried then; I knew how unlikely it'd be that insurance would pay for any of this. I didn't get any 'phobic vibes from the lady taking my appointment, but she did confirm my suspicions that they didn't have much experience with "someone like me".

This is my main worry. My doctors have been pretty clueful when it comes to insurance companies. This time, I had no choice but to take a chance.

So...six weeks later, I show up with all the forms they need. When they ask for my insurance card, I give it to them. When I finally meet with the doctor, he reveals that: 1. They apparently noted my trans status all over my files. 2. Neither he nor his center has ever (knowingly) had a trans client. When we get to the end of the meeting, he tells me I have to fill out yet another form before I can start the actual deposits. In the section marking reasons, he wrote in "Prior to treatment medically or surgically for gender change". I had no problem with that until he told me he was going to submit just that to the insurance company. I told him that might not be the best of ideas, but he told me to go talk to the billing department. I asked that they submit it, but to refuse requests for that kind of information. She said she'd "make a note of it".


I guess my nightmare scenario is that my insurance company sees this and uses it as an excuse to stop paying for so much as a flu shot. Am I being paranoid, or should I worry? Should I have just paid up front for the entire thing and told them not to send anything to insurance? Turns out there is a standard check box for "in anticipation of orchiectomy". Should I ask him to change the reasoning to that or would it raise even more eyebrows?

*sigh*

[Michelle.]

Have you read over the documents that came with your policy?

Remember your carrier will reimburse whatever the policy covers.

You can always appeal their decisions, using their internal process.

[Maya Zimmerman]

Well, insurance in the US is a pretty tricky world to navigate, made only more tricky by being trans, but as much as insurance companies will be "the bad guy" to make money, they won't do anything illegal.  Essentially, your best weapon is understanding.

First of all, your being open and honest in all medical situations, while potentially devastating in the past, is exactly the right move now!  Part of the Health Care Reform bill was that, starting in 2010, insurance companies are no longer allowed to rescind coverage due to incorrect information unless the statement was fraudulent or intentionally misleading.  The most misleading aspect of hiding a condition would likely be fear that you would not be eligible for insurance due to a pre-existing condition, which in turn is being abolished starting in 2014, also as part of the Health Care Reform bill.  So, your providing that information will not allow your insurance company to rescind coverage, especially since the pre-existing nature of gender identity disorder is itself highly debatable.  Yes, I knew from an early age that I was the wrong gender, but I didn't know it was a medical condition, there's no check-box for it in medical history forms, and like most of us, I spent years understanding and coming to grips with it.

So, to be clear, whatever you do, do not ask the clinic to intentionally provide fraudulent information to the insurance company, as it is the ONLY way they will legally be allowed to rescind coverage and if they're allowed to, they will.

Being upfront with my insurance company has been great.  I called and asked about in-network therapists who specialize in GID and was given a list.  Other than therapy, the only thing I know that most insurance companies cover for transition is hormones, but we need all the help we can get, right?

[Annah]

if your insurance company has exclusions on HRT and Therapy for transgender people then you may have inadvertently made it harder for yourself by calling your insurance company and telling them you are transgender.

Many doctors, mine included, coded the insurance paper work for my therapy as "depression" and my HRT as "hormonal imbalance."

However, if there is any notation in your file that you are transgender, then these "shadow codings" will be very hard to get passed the insurance claim adjusters.

I worked for some medical insurance agencies and a disability insurance agency as a claim manager. Whenever there is a red flag (an occurrence that may make someone ineligible for types of insurance) it is entered into your file electronically so it will be extremely hard to miss. Also, red flag files are almost always placed into Supervisor's hands; meaning, while a claim adjuster or claims handler can review your case and the processes, it will require a supervisor final check and approval before the checks are disbursed to the medical facility in which the paperwork originated from.

For everyone else, if your insurance contractual guidelines excludes transgender coverage, please please please do not tell your insurance provider you are transgender. Your doctors can always, legally, find a loophole around your coverages if your insurance company does not know you are transdender. Once they know you are transgender and you and your doctor tries to code it as something else, they can potentially get you and your doctor for fraud. Usually, the insurance company will deny the claim, send a letter of explanation to the doctor and then the doctor will charge you for the money she or he was suppose to get from the Insurance Carrier. This can add up if substantially you have a lot of submissions from your doctor to your insurance company.

[Annah]

They wont deny you for a flu shot, but when it comes to orchi, deviated septums, HRT, therapy, anything that could be even remotely related to a transgender issue, they will closely scrutinize the claim you filed...once they discover you are transgender.

And trust me, Insurance companies knows A LOT about transgender procedures that requires medical intervention. Most of the transgender steps that I needed to take to get SRS, I learned from working for Liberty Mutual.

Insurance providers has a floor of doctors of every specialization you can ever think of within their offices. Sometimes, a seasoned insurance coordinator will know more about your condition than your doctor will!

[Maya Zimmerman]

Annah - My current insurance policy does not have transgender therapies in the exclusions.  Is it even legal to have such an exclusion these days?  Further, wouldn't being upfront and honest, as I said before, prevent them from being able to charge you with fraud?  Meanwhile, wouldn't going out of your way to lie about who you are and what you're having done in order to be covered for procedures that your insurance doesn't cover quite specifically be fraud?  I have to say I'm a little shocked that you would take manipulation of your insurance so lightly given your stance on student loan appropriation.  I guess we each have our own boundaries, ne?

[Annah]

Annah - My current insurance policy does not have transgender therapies in the exclusions.  Is it even legal to have such an exclusion these days?  Further, wouldn't being upfront and honest, as I said before, prevent them from being able to charge you with fraud?  Meanwhile, wouldn't going out of your way to lie about who you are and what you're having done in order to be covered for procedures that your insurance doesn't cover quite specifically be fraud?  I have to say I'm a little shocked that you would take manipulation of your insurance so lightly given your stance on student loan appropriation.  I guess we each have our own boundaries, ne?

If your insurance company is a private company (ie., not medicaid( they can put whatever exclusions they want (in cooperation) with your job. When an employer sets up medical insurance they meet with a liaison from the insurance company to fashion and create a medical contract that suits the employer. The more exclusions a specific contract has, the cheaper the contract will be for your employer. For example,many insurance companies cover SRS if the employer wishes that exclusion to become an inclusion to the policy. Right now, HRC and other non profits are educating businesses that including SRS will not dramatically increase their policy costs.So basically, if your employer wanted hospitalization psychiatric care to be an exclusion to make the policy cheaper they can do that (if your employer is a private firm).

And legal loopholes cannot get you in trouble. The worse that could happen is if the insurance company catches the diagnosis of "hormone imbalance" as an inaccurate diagnosis they would simply tell the doctor to please code it correctly next time. For the most part insurance companies to not make a hassle. It's when a doctor or the patient calls into their insurance carrier and then tells them they are a situation that is an exclusion to a specific policy and repeatedly codes a diagnoses the wrong way that can get a doctor or patient in trouble.

You wouldn't be going out of your way to lie if your doctor codes it so it can be covered. However, it would be considered going out of your way if you tell your insurance company you are an exclusion and then try to get around it.

But whatever the case, it is up to you and your doctor. If you are an exclusion and you feel bad then don't get the treatment.

[Maya Zimmerman]

Intriguing.  I guess I really don't know much at all about insurance.  Thanks for picking up my mistakes here, Annah.  I guess I gave raya some bad advice. 

[Annah]

your advice is fine.

The only thing I would slightly disagree with is your comment about 2010 and Insurance companies not having the ability to deny your claim because of misinformation.  If there is an exclusion for certain transgender medical care and they find out, the 2010 bill would not apply. That was more under "pre-existing conditions" which could affect a trans person even if they did have contractual language allowing transgender coverages.

I am just explaining how those in the Insurance Company ticks. But every policy, every employer, and every insurance company is different so the best course of action for her is to contact her human resource officer and explain the situation.

[Raya]

Thank you all for responding so quickly. I'm sorry you all had to wait until I came back from work for a response. This was the one wrinkle in an otherwise great day. Happily, after a six week wait for the consultation, I only have to wait six days to make a deposit!

@Michelle.: According to my insurance policy they have an almost blanket exclusion on fertility treatments and transgender care.

@Maya: Maybe I've seen Sicko one time too many, but AFAICT "rights" don't mean squat if you don't have the time and money to assert them in court. I'd rather it not get to that point.

@Annah: Oh, no, no, no! I haven't told the insurance company anything! I told all this to the infertility clinic! Unless, of course, you're saying that that distinction doesn't matter...

My GP and therapist are well-regarded by the local trans community. They do almost the exact same thing as yours when it comes to insurance coding. The infertility clinic was a complete unknown. I didn't see any harm in telling the infertility clinic because I knew there was next to no chance of insurance covering sperm banking. What I didn't know is how blithely the infertility clinic would write my trans status all over their files.

My worry is how much the infertility clinic will respect my wishes to not share this information with the insurance company. My worry is how much my wishes even matter at this point. I'm definitely going to try to halt any submission first thing tomorrow morning. Since you've had experience, can you tell me how much power the insurance company has to demand the information from the infertility clinic? So long as that's where it stays, I don't really much mind them knowing...

[Maya Zimmerman]

Oh no! I am the Human Resources department at my work!

The thing about 2010 was in reference to the ability to rescind coverage due to incorrect information, not about denying a claim.  There were apparently companies dropping cancer patients, whose treatments' costs would easily outweigh premiums paid, by finding tiny errors like forgetting to mention having chicken pox as a kid on a medical history and things like that.  Now, they have to show that you were intentionally misrepresenting information in order to cancel your policy.

At least, that's how it's explained in the little guide of changes due to Health Care Reform I got from our former insurance administrator.

[Annah]

@Annah: Oh, no, no, no! I haven't told the insurance company anything! I told all this to the infertility clinic! Unless, of course, you're saying that that distinction doesn't matter...

My GP and therapist are well-regarded by the local trans community. They do almost the exact same thing as yours when it comes to insurance coding. The infertility clinic was a complete unknown. I didn't see any harm in telling the infertility clinic because I knew there was next to no chance of insurance covering sperm banking. What I didn't know is how blithely the infertility clinic would write my trans status all over their files.

My worry is how much the infertility clinic will respect my wishes to not share this information with the insurance company. My worry is how much my wishes even matter at this point. I'm definitely going to try to halt any submission first thing tomorrow morning. Since you've had experience, can you tell me how much power the insurance company has to demand the information from the infertility clinic? So long as that's where it stays, I don't really much mind them knowing...

If your insurance company will not accept the claim because sperm freezing isn't covered then I would not see why the clinic would contact them at all.

Since the insurance company will have nothing to do with the procedure then the clinic really shouldn't be transmitting data to your insurance company.

[Cindy Stephens]

The clinic may have no idea at all whether or not the procedure is covered by your insurance and may submit it "just in case."  Most medical practices have some sort of blanket release that you are required to sign that releases them under various hippa rules and other right to privacy codes, rules, etc.  Just to throw a little paranoia out there, a lot of people are not aware that the medical profession has access to a vast database of your history, procedures, and medications.  It is very similar to your credit history.  Doctors use it to check if you have ever sued a medical practioner, have a mental illness, are doctor shopping for narcotics, etc.  I really don't know how detailed it is.  I had read about it in passing, but ran into its' reality when I first started seeing my psychiatrist about 6 years ago.  One of the intake questions was whether I had seen a therapist previously.  I said, truthfully so I thought, no.  At the second meeting she commented that I had seen one in 1972 for a short period.  I had been drafted and really didn't want to go to Nam so had done every procedure to get my induction notice overturned.  I did manage to get a 4F for other reasons.  Seems they didn't take transgender homosexuals, whether you had a shrinks note or not.  I comment on this because your prescriptions etc. are probably on file and available anyway.  It just depends on how rigorous the other party is in finding out about your health history.  Sorry, but true stealth is a fiction in this society.       

[Annah]

in the US a doctor cannot obtain your records from a previous doctor unless you sign a written consent that the new doctor can have access to your medical files.

Also, if a larger corporate entity such as Kaiser, anyone within that network will have free information to your medical history (one of the main reasons why I cannot stand huge medical corporations. Kaiser pretty much owns the state of California. Some scary sh*t.

Also, if a hospital is own by a parent company, then that parent company has the right to transmit your medical records to other hospitals throughout the country to other hospitals under that company. However, if a hospital is owned by one company but then there is another hospital 2 blocks away owned by another company, they will not have access to each other's medical information unless you request it.

Also, I think your psychiatrist found out you had therapy 30 years ago because when you go to a doctor's office for the first time, part of the paper work you sign is also permission to obtain all other previous medical records that pertain to you. That is how she found out. It's usually the third or fourth form in the new patient packet you fill out.