Getting Insurance Companies To Help With Surgeries

[Julie Marie]

We all know most health insurance policies won't cover SRS, FFS or any other "elective" surgery we feel we need.  It would cost them too much.  But what if they created a rider for these surgeries that would substantially reduce our cost?

We all know insurance companies reduce what doctors would charge a person coming off the street.  Sometimes it's pretty substantial.  One forum had a doctor who itemized what she makes for a specific surgery and what a FFS surgeon makes for a similar procedure.  The FFS surgeon made about 20 times more!

There's a local board certified surgeon who has done FFS surgeries and people who have seen the results say he's an artist.  His charge is about 1/3 what well known FFS surgeons charge.  That means there's a lot of wiggle room here.

If insurance companies created a "TS rider" for a given surgical procedure, could they negotiate a lesser charge with the surgeon and still make some money for themselves?  In other words we'd be paying them to negotiate a better price for us.

Example: Aetna has a rider for SRS that costs $14,000.  If you go pay it yourself it will cost you maybe $16-20K.  Aetna negotiates the fee with the surgeon and charges something for their time.  The surgeon gets maybe $13K and Aetna gets the rest.  Seems like a no brainer, if the demand is there.  Of course we'd all have to jump on the bandwagon or these surgeons might turn away anyone with an insurance policy.

Is anyone in the insurance business?  Does this sound feasible?  If so, how would you go about instituting something like this or at least finding people who will listen?

My guess is if the insurance companies open their doors to this it could eventually lead to complete coverage for us or at least at a substantially reduced rate.

Julie

[beth]

            Purchasing a complicated service such as FFS is not like buying a car. All cars of the same model are created equally so they can be compared directly and those desperate to sell will sell at a lower price. Competent creative people deserve to be paid more. Forcing them to fit within a certain price target will lower the quality of the service. 





beth

[DawnL]

Physicians are not compelled to accept reduced payments from insurance companies unless they specifically agree based on
a uniform plan such as an HMO or PPO (Preferred Provider Organization).  SRS and FFS surgeons who are in high demand would
have no incentive to join into such an arrangement.  Marci Bowers for instance has a 6-8 month waiting list as it is.  The fact
that highly gifted surgeons can demand more for their services and receive it is proof that our free-enterprise economic system
is alive and well.  When government or insurance guidelines are forced on such people, they tend to move to places that still
operate with free-enterprise rules, a phenomenon referred to as a "brain drain".  That is not a good thing.

Dawn

[Julie Marie]

Beth and Dawn, I've thought about what you've both mentioned but if these surgeons are overcharging us how can we protect ourselves?  And I'm thinking more of FFS surgeons than SRS surgeons.  That's where I see most of the problems.

There will come a time when these surgeons aren't few and far between.  The money will bring them in.  For now we're stuck with supply and demand but if this idea is going to work all of us would have to be onboard.  And I highly doubt a surgeon will walk away from the practice because she/he is getting dinged for a few bucks.  Insurance companies have been doing this for some time now and there's no shortage of good doctors.

I know some doctors won't accept insurance company terms and make you pay whatever the insurance company doesn't.  And if you can afford it, great.  But I've been able to find competent doctors who take my insurance, no problem.  I don't live in Tinsel Town and I can't afford whatever a doctor wants to charge nor can I justify creating for myself the financial hardship by paying whatever they want to charge.

SRS is not elective surgery for us.  It's a medical necessity and should be treated as such.  And FFS is close behind.

Julie

[HelenW]

It was made illegal for insurance companies to refuse breast reconstruction after mastectomy even though this is maily a cosmetic improvement.  Why?  Because the legislatures were finally convinced that the option of breast reconstruction was necesssary for a woman's peace of mind and psychological health.

With the ongoing push towards nondiscrimination laws that include gender identity as well as orientation, I think the insurance companies should be held to the same standard for TS people as they are for women who have lost their breast to cancer.

It is STILL a very common belief in the world that SRS is and should remain an elective, cosmetic surgery.  This too should change.  Until then (and the insurance companies will resist this to their utmost ability) we will have no luck changing the insurance companies' policies.

Working with insurance companies the way Julie has proposed is not the answer, in my opinion.  Insurance companies routinely cover organ transplants and other much more expensive procedures.  They don't refuse SRS because it costs too much, they deny it because they can.  And the money they save goes right to their bottom line.  They will continue to refuse it until they are forced to accept the charges through legislation.

smiles & hugs (for those NOT writing those policies)
helen

[BrandiOK]

Here's the way I see it.....

  A general physician attends four years of pre-med, four years of medical school and then enters into a one year internship followed by a one year resident physician position THEN can go along thier merrry way and choose a specialty.  Obviously plastic surgery entails several more years of intense training especially when SRS is concerned.  Along with all of this comes HUGE debt for most physicians, outrageous malpractice insurance fees, frivolous malpractice lawsuits AND the headaches associated with dealing with the evil insurance companies.

  Now...think about the stigma involved with transgendered people in general.  This same stigma occurs in the medical community and surgeons who take on such a specialty of FFS or SRS are subject to the same types of silent condemnation from many of their peers. 

  While it's true doctors/hospitals often overcharge insurance companies for thier services this is done simply to try and recoup a small percentage of money lost to patient non-payment and ever increasing strict policies by the insurance companies that are obviously to save them money.  When I worked on an ambulance it was standard practice to charge 50 to 75% markups to the insurance company...this once again was because it is very difficult to get the insurance companies to pay up on claims.  They know they can hold out forever while a hospital or ambulance service has to have the income to survive and thus the more difficult they make it on the service provider the less they can pay out eventually. 

  My endocrinologist recently stopped accepting insurance coverage.  While she understands that many of us depend on the insurance companies to be able to afford care she also has a business to run.  She can't provide the service if she can't afford to operate her office, pay her employees, pay her god aweful high insurance premiums and make enough money so support her family in a way that she has most certainly earned.  It's very difficult for me to afford to see her now because the insurance company doesn't want to reimburse me for services she has provided (one of those nasty little things that insurance companies do to show that they are the boss 'not gonna work with us huh? We'll just stop reimbursing your patients for your services and show you.').  She does, however, take these things into consideration by giving me a little more time in between visits and discounting her service to help make it more affordable.  I will continue to see her simply because she's the best in this area and she genuinely cares about her TS patients.

  I suppose my point is simply a counter point to what I have read....the fact that most SRS surgeons don't deal with insurance companies means that they are not so inclined to jack up prices to offset losses.  Considering the educational backgrounds of these medical professionals and the sheer dedication they show to helping transsexual patients I am thankful that surgeons such as Dr. Brassard and Dr. Bowers offer these services for the price they charge....in comparison to reconstructive plastic surgeries for non TG related issues this cost is relatively low and these doctors have managed to keep them low because they understand that more often than not we are generally not wealthy patients and we will almost certainly be paying out of pocket.

  Oh yeah....insurance companies are evil incarnate.  I beautiful concept gone HORRIBLY wrong....once again it proves that human beings are dispicable creatures (but that's another rant to be saved for another day)

[cindianna_jones]

When I had my surgery, it cost $7500.  I had back surgery a few years before that and it cost $22,000.  Granted the two are vastly different specialties.  But for the vaginaplasty, I think I got a really good deal from Dr Biber.  I did manage to get my insurance company to cover it too.  The legal letters I sent convinced them it was cheaper to pay for the $7500 surgery than go to court over it. I didn't get legal help, but I wrote some pretty convincing letters.  But this was after the fact.  I'd hate to have had the insurance company involved with Dr. Biber.  They always seem to get there beaurocratic fingers in everything where they shouldn't.

For FFS, I would want an artist.  A difference of a few thousand seems like a lot, but in the large scheme of things, it is your face after all.  Many people spend much more than this on a single car.  I can garantee that if insurance companies or the governement gets involved, the artists will find some way out of it... and then we might not have access to them at all.

I hate the insurance companies involvement in medical care, period.  They skim 20 to 30 percent of the total medical bill.  I sure would like to limit THEM as part of the process or get rid of them altogether. 

Julie, your idea shows creative thinking.  While I don't think it is terribly practical, it is totally unique!  You keep coming up with those good ideas!  That's what we need... more creative thinkers.  We need to find the holes in the system and make them useful for us.

Cindi