Somebody I spoke to said he had top surgery completely covered by insurance which was amazing to me. I'm not sure if this works, or who would be comfortable with it but free surgery? Sounds like a good thing to me!

Pretty much this guy had approached it with the intent of having a family history of breast cancer. He had to get mammograms and he had top surgery as a preventative measurement against breast cancer. Or at least, that's how it was coded on paperwork. It was really just getting top surgery.

The only problem with that is you have to find a surgeon who is willing to construct your chest in a male fashion during the surgery.  There is also the "reduction" method, if you can find a surgeon who will take you all the way down and reconstruct your chest in a male manner.  I've definitely heard of both methods being used but you have to find the right surgeons.

Quote from: Andy8715 on February 04, 2012, 11:10:07 PM
The only problem with that is you have to find a surgeon who is willing to construct your chest in a male fashion during the surgery.  There is also the "reduction" method, if you can find a surgeon who will take you all the way down and reconstruct your chest in a male manner.  I've definitely heard of both methods being used but you have to find the right surgeons.

Can't go to a top surgeon (ex: Garramore) and have them sign it off as preventing breast cancer?

This would fall under health care fraud.  Yes, there are some understanding physicians out there, but this type of leniency is usually because the healthcare provider and administrators want to bill the insurance for more services and are even willing to bill non-covered services as visits/procedures that are covered in order to bring in more $$$.

Hmm...I'm sure some might but probably not that many.  Garramone definitely does not though.  I don't think he messes with insurance at all.  Not sure about anyone else.

Quote from: Epi on February 05, 2012, 12:31:55 AM
This would fall under health care fraud.  Yes, there are some understanding physicians out there, but this type of leniency is usually because the healthcare provider and administrators want to bill the insurance for more services and are even willing to bill non-covered services as visits/procedures that are covered in order to bring in more $$$.

I don't believe getting a legit reduction but having more tissue taken off than usual is fraud.  It's still a reduction.

Quote from: Nygeel on February 04, 2012, 11:20:36 PM
Can't go to a top surgeon (ex: Garramore) and have them sign it off as preventing breast cancer?

Garramone doesn't deal with insurance, but there are some surgeons out there who are known for top surgery who do, not sure the exact ones though.

Quote from: Andy8715 on February 05, 2012, 07:54:31 AM
I don't believe getting a legit reduction but having more tissue taken off than usual is fraud.  It's still a reduction.

The intentional deception for personal gain is fraud.  Now, having one procedure performed under the "guise" of something else that is covered even though in actuality you are having a different procedure that isn't covered is fraud.   

If a patient had breast reduction to reduce back pain, etc after other options had failed, that would be covered.  Now, if a patient claimed back pain and found a physician/surgeon willing to "perform" a "reduction" but in reality it was a complete mastectomy with chest reconstruction, that would be fraud.  There's a lot of reasons medical insurance and billing policies are so screwed up, but committing fraud isn't the solution.

Then don't most of us need some sort of health insurance fraud in order to get some coverage? Like marking on insurance male, and saying we have low testosterone to cover hormones...or anything like that? I know if you say "GID" then you tend to not get coverage.

Quote from: Nygeel on February 05, 2012, 05:39:11 PM
Then don't most of us need some sort of health insurance fraud in order to get some coverage? Like marking on insurance male, and saying we have low testosterone to cover hormones...or anything like that? I know if you say "GID" then you tend to not get coverage.

I guess I see it a little differently.  How is putting "male" on insurance fraud?  I am a male, just an "atypical" one.  I'm not sure what my endo puts.  Either hypogonadism (which I've told her I wasn't comfortable using) or endocrine disorder NOS (which was my initial suggestion).  Low T was another one of her options.  I do have naturally low T, so why not put it?  I have a medical condition in which I have lower amounts of testosterone than the average male, but it's not exactly hypogonadism or another easily codable condition.  So to me endocrine disorder NOS fits.  Whatever she puts I'm sure that she can back it up legitimately.  This woman isn't about to risk her license over me. 

I know of another trans guy who used to help others get surgeries legally covered by insurance.  Sometimes even in cases where the policy excludes trans related surgeries.  Unfortunately he isn't offering those services anymore.  There are some of his tips on various yahoo groups though.  You may have already heard of him since you live in NY.  If you want, I can PM you info I have on him.

Quote from: Nygeel on February 05, 2012, 05:39:11 PM
Then don't most of us need some sort of health insurance fraud in order to get some coverage? Like marking on insurance male, and saying we have low testosterone to cover hormones...or anything like that? I know if you say "GID" then you tend to not get coverage.

I think that a legal female can be prescribed testosterone if the doctor bills it as hypogonadism on the insurance or a hormone imbalance.

Quote from: Adio on February 05, 2012, 06:02:09 PM
I know of another trans guy who used to help others get surgeries legally covered by insurance.  Sometimes even in cases where the policy excludes trans related surgeries.  Unfortunately he isn't offering those services anymore.  There are some of his tips on various yahoo groups though.  You may have already heard of him since you live in NY.  If you want, I can PM you info I have on him.

He still does it but you have to go through his website, and he charges based on how thoroughly you want your insurance plan looked at and how many suggested doctors, etc you want.  That is, if you are talking about who I think you are.

Quote from: Nygeel on February 05, 2012, 05:39:11 PM
Then don't most of us need some sort of health insurance fraud in order to get some coverage? Like marking on insurance male, and saying we have low testosterone to cover hormones...or anything like that? I know if you say "GID" then you tend to not get coverage.

Where's my red pen?!  I get what you're asking and while doing things the honest way can be more time consuming and frustrating, just because it's more difficult doesn't mean you need to resort to fraud.  There are plenty of other options that don't include fraud such as private insurance individuals can obtain, plenty of public (and private) university systems, public/private sector jobs, etc offer health insurance that also covers HRT/SRS.  There's also a lot of clinics aimed at providing medical care to low-income individuals at a signifncantly reduced cost that also provide a lot of services for transgender patients. 

Fraud is both a criminal and civil matter, in most states the statue of limitations is 7 to 10 years.  By committing fraud you run the risk of facing a whole gauntlet of legal consequences from jail time, to paying restitution, to forfeiture of assets (if they're not seized) to pay judgment.  You basically would mark yourself for life as un-insurable unless you were willing to pay a ridiculously high premium or had a damn good union job.

Committing medical insurance fraud only lines the doctors and medical insurance companies pockets with more money and puts individuals such as you and I at a great disadvantage. 

Quote from: Epi on February 05, 2012, 06:21:11 PM
Where's my red pen?!  I get what you're asking and while doing things the honest way can be more time consuming and frustrating, just because it's more difficult doesn't mean you need to resort to fraud.  There are plenty of other options that don't include fraud such as private insurance individuals can obtain, plenty of public (and private) university systems, public/private sector jobs, etc offer health insurance that also covers HRT/SRS.  There's also a lot of clinics aimed at providing medical care to low-income individuals at a signifncantly reduced cost that also provide a lot of services for transgender patients. 

Fraud is both a criminal and civil matter, in most states the statue of limitations is 7 to 10 years.  By committing fraud you run the risk of facing a whole gauntlet of legal consequences from jail time, to paying restitution, to forfeiture of assets (if they're not seized) to pay judgment.  You basically would mark yourself for life as un-insurable unless you were willing to pay a ridiculously high premium or had a damn good union job.

Committing medical insurance fraud only lines the doctors and medical insurance companies pockets with more money and puts individuals such as you and I at a great disadvantage.

This is my situation...I get my health insurance from my parents. I have severe problems that make it hard to get a job (let alone a full time job). Trying to find a job that I'm able to do, and will hire me full time, and give me insurance that will cover everything is very very very hard to find. Places may provide medical care (Ex: hormones) to trans people at sliding scale if they don't have insurance where as if you do have insurance and the insurance doesn't cover it, you're out of luck. On top of that, there's almost no coverage for surgery.

Look, I get what you're saying but I think that it might be worth the risk for some people. I know getting enough money for surgery would end up taking me years upon years upon years. I also know that there are a lot more people out there in worse situations than I'm in that have way more extreme body discomfort. Whole health care system is in need of a fixin'. 'Cause the way it is now, we're all screwed.

Quote from: Nygeel on February 05, 2012, 05:39:11 PM
Then don't most of us need some sort of health insurance fraud in order to get some coverage? Like marking on insurance male, and saying we have low testosterone to cover hormones...or anything like that? I know if you say "GID" then you tend to not get coverage.

Pretty much, and I don't feel guilty about it either.  I pay nearly $200 a month for my (high deductible) health insurance, only to have Humana deny my HRT blood work claims through my previous physician, because they were billed with the 'correct' codes, and my plan had trans-exclusions (which wasn't mentioned in my benefits description, either, mind you).

Now I go to Howard Brown Health Center in Chicago (a 10 hour round trip), and they bill it as an endocrine disorder, so it's covered.   Howard Brown does sliding scale for those without health insurance, but since I actually have health insurance, I don't qualify.   Dropping my health insurance to get into their low-income HRT program would be irresponsible due to my other health conditions.   For years I didn't have health insurance and the tax payers got to cover my ER visits.  I feel way worse about that than I do Howard Brown making Humana cover some blood work for a plan both my employer and I pay out the nose for.

Howard Brown has good lawyers, they can legitimize their diagnosis of endocrine disorder if need be (and certainly in my case since the T keeps my endometriosis symptoms almost non-existent after other treatments failed), but even if they couldn't, I wouldn't be the one in trouble for committing fraud.

It's a really nice, pie-in-the-sky idea that trans people should just look for jobs with insurance that cover their treatment, but logistically, most people aren't in a great position to be finding new jobs during transition.  It's a horrid job market for anyone right now, let alone if you don't pass or if your documents don't match up.  Private insurance is prohibitively expensive (and are great at crying 'pre-existing condition!' to avoid coverage), college is prohibitively expensive, and it's shocking how few LGBT clinics there are that actually provide HRT services.

The fact is, insurance companies should be covering these things anyways (actually, we should have socialized medicine, you can't claim to be the greatest country on earth when over a quarter of your citizens can't get antibiotics).  By all means, exhaust all the proper, legit channel methods first before resorting to 'creative billing' (I sure did), but if you're got a practitioner or surgeon who knows how to swing things in your favor, I certainly don't judge anyone for it.   

Quote from: Nygeel on February 05, 2012, 06:32:32 PM
This is my situation...I get my health insurance from my parents. I have severe problems that make it hard to get a job (let alone a full time job). Trying to find a job that I'm able to do, and will hire me full time, and give me insurance that will cover everything is very very very hard to find. Places may provide medical care (Ex: hormones) to trans people at sliding scale if they don't have insurance where as if you do have insurance and the insurance doesn't cover it, you're out of luck. On top of that, there's almost no coverage for surgery.

Look, I get what you're saying but I think that it might be worth the risk for some people. I know getting enough money for surgery would end up taking me years upon years upon years. I also know that there are a lot more people out there in worse situations than I'm in that have way more extreme body discomfort. Whole health care system is in need of a fixin'. 'Cause the way it is now, we're all screwed.

I know a number of individuals whose grad schools insurance covered HRT/SRS.  That may be a very viable option for you.  Others volunteered at LGBT non-profits and eventually were offered paying positions that came with coverage.

It may be worth the risk now but later on what if you or someone on the policy has a major illness or suffers a serious injury?  The insurance company is going to look through everything with a fine tooth comb doing everything possible not to pay.  If you want to commit fraud move to Alabama, the statue of limitations is only 2 years so long as it's not tax evasion.

Quote from: Bahzi on February 05, 2012, 07:04:40 PM
Pretty much, and I don't feel guilty about it either.  I pay nearly $200 a month for my (high deductible) health insurance, only to have Humana deny my HRT blood work claims through my previous physician, because they were billed with the 'correct' codes, and my plan had trans-exclusions (which wasn't mentioned in my benefits description, either, mind you).

Now I go to Howard Brown Health Center in Chicago (a 10 hour round trip), and they bill it as an endocrine disorder, so it's covered.   Howard Brown does sliding scale for those without health insurance, but since I actually have health insurance, I don't qualify.   Dropping my health insurance to get into their low-income HRT program would be irresponsible due to my other health conditions.   For years I didn't have health insurance and the tax payers got to cover my ER visits.  I feel way worse about that than I do Howard Brown making Humana cover some blood work for a plan both my employer and I pay out the nose for.

Howard Brown has good lawyers, they can legitimize their diagnosis of endocrine disorder if need be (and certainly in my case since the T keeps my endometriosis symptoms almost non-existent after other treatments failed), but even if they couldn't, I wouldn't be the one in trouble for committing fraud.

It's a really nice, pie-in-the-sky idea that trans people should just look for jobs with insurance that cover their treatment, but logistically, most people aren't in a great position to be finding new jobs during transition.  It's a horrid job market for anyone right now, let alone if you don't pass or if your documents don't match up.  Private insurance is prohibitively expensive (and are great at crying 'pre-existing condition!' to avoid coverage), college is prohibitively expensive, and it's shocking how few LGBT clinics there are that actually provide HRT services.

The fact is, insurance companies should be covering these things anyways (actually, we should have socialized medicine, you can't claim to be the greatest country on earth when over a quarter of your citizens can't get antibiotics).  By all means, exhaust all the proper, legit channel methods first before resorting to 'creative billing' (I sure did), but if you're got a practitioner or surgeon who knows how to swing things in your favor, I certainly don't judge anyone for it.

Bahzi, I would have less of a problem with a physician billing for something else if the person barely could afford their sub-par medical coverage premium, but you can afford to pay your $200 premium.  While you may be saving some $$$, someone else is having to pay more to make up the difference and it's certainly not the doctors that are paying that.  Also, with recent healthcare reform you can't be denied based on a preexisting condition.  Even though some of these provisions of Obama's health care reform don't go into full effect until 2014, you still have other options.

While Howard Brown may have good malpractice lawyers, you as the patient are still responsible for your share of the coverage.  Later down the line say you're in a car accident and break your leg, requiring surgery and hospitalization.  They're going to nit pick everything and unless the another party was at fault don't expect your insurance provider to see what extra services they can provide you with, they're going to make sure you pay every cent.  You think $200 is high now, wait til your credit ruined and you have a collection agency after you.

Fraud isn't a joking matter and committing it doesn't fix any of the problems associated with medical coverage.  In the end, someone else, such as myself, pay more than their fair share because you won't and that's not right.  (Next the federal government will bail them out too!)

Planned Parenthood has HRT services for transgendered patients, as I recall, there are a lot of Planned Parenthoods.  Also, Bahzi is it absolutely necessary you take the insurance offered by your employer?  Is there an opt-out option so you can find your own coverage (possibly where your employer pays a percentage of it)?

Quote from: Epi on February 05, 2012, 07:41:58 PM
I know a number of individuals whose grad schools insurance covered HRT/SRS.  That may be a very viable option for you.  Others volunteered at LGBT non-profits and eventually were offered paying positions that came with coverage.

It may be worth the risk now but later on what if you or someone on the policy has a major illness or suffers a serious injury?  The insurance company is going to look through everything with a fine tooth comb doing everything possible not to pay.  If you want to commit fraud move to Alabama, the statue of limitations is only 2 years so long as it's not tax evasion.

I don't go to school. I graduated from community college a year ago. I currently volunteer at an LGBT youth center but they only hire people with masters degrees and don't pay well.

If I could afford to move to Alabama I probably could afford transition expenses.

Quote from: Nygeel on February 05, 2012, 08:01:15 PM
I don't go to school. I graduated from community college a year ago.

Well, this actually changes everything.  I was under the impression based on past postings that you had graduated from a 4-year.  Why not apply to a public 4-year university with medical student insurance that covers HRT/SRS and apply for FAFSA since you qualify?

Quote from: Epi on February 05, 2012, 08:11:32 PM
Well, this actually changes everything.  I was under the impression based on past postings that you had graduated from a 4-year.  Why not apply to a public 4-year university with medical student insurance that covers HRT/SRS and apply for FAFSA since you qualify?

I don't qualify for FAFSA, and with what I have a degree in, going to a 4 year wouldn't exactly be a great choice.

Quote from: Nygeel on February 05, 2012, 08:24:50 PM
I don't qualify for FAFSA, and with what I have a degree in, going to a 4 year wouldn't exactly be a great choice.

May I ask why you don't qualify for FAFSA?

Quote from: Epi on February 05, 2012, 08:27:39 PM
May I ask why you don't qualify for FAFSA?

My parents, although together their combined income is barely enough to live where we are is too much for FAFSA. When it was myself, and my two younger brothers in school at the same time we didn't qualify while making the same income as we do now.

Quote from: Nygeel on February 05, 2012, 08:31:17 PM
My parents, although together their combined income is barely enough to live where we are is too much for FAFSA. When it was myself, and my two younger brothers in school at the same time we didn't qualify while making the same income as we do now.

This was an issue for me too.  Even though I lived separately from my parents I was still considered dependent but by the time the year of my 24th birthday rolled around, that no longer applied.  Since you're 24 years old now Nygeel; even if you still live at home, you're now considered independent by FAFSA.  "Be 24 years of age or older by December 31 of the award year"  Your parents income is now irrelevant.