Scheduled my Consult!

[CursedFireDean]

I scheduled my consult for top surgery! I'm seeing Dr. Keelee Macphee, she is local and the only top surgeon that my insurance said was in network. Her office said she's out of network for all insurance, so I'm gonna discuss that with them when I come in.

My consult is next Tuesday, I'm so excited
She said the consult fee is $100

I'm not 100% sure if insurance will cover top surgery but I'm going to fight for it and appeal if they say no (which they probably will). If they do cover it, I'll fight to get her covered as in-network since nobody else does this surgery. So there's still a long road ahead but I'm at least starting! My sister has a lot of medical expenses, so we generally get pretty close to our family out-of-pocket maximum, so hopefully I won't have to pay much.

[FTMax]

Congrats Dean!

If there's nobody in network, you probably won't have to fight as hard as you think to get her covered at the in-network rate. That would be a deficiency in the network. You may still have to do a bit of leg work, but it's probably not as hard as having to appeal an entire decision as to whether or not to cover the procedure in general.

Best of luck! Let us know how your consult goes.

[CursedFireDean]

Congrats Dean!

If there's nobody in network, you probably won't have to fight as hard as you think to get her covered at the in-network rate. That would be a deficiency in the network. You may still have to do a bit of leg work, but it's probably not as hard as having to appeal an entire decision as to whether or not to cover the procedure in general.

Best of luck! Let us know how your consult goes.

Thanks! And that was my hope too- after going through the appeal process (I already know for sure that it's gonna have to happen), fighting for in-network coverage really won't be as hard. They make it pretty clear on their site that they'll do that for deficiencies, plus if I appeal and go through all that, they'll know already that I am perfectly willing to fight.

I'm definitely going to update after the consult! It's very hard to find information about her online and anything I did find was usually 2012-2013 era which isn't very representative of her work today. Hopefully I can add to the small pool of information.

[CursedFireDean]

Update: The consult went really well! I liked her a lot and felt super comfortable with her, and she had good answers for all of my questions. She also said top surgery is her most common surgery which made me feel more comfortable.

As for a surgery date, it depends on insurance. Here'a where I'm at:

I have a blanket exclusion on trans stuff right now
1. I was going to fight the exclusion. In theory if it succeeded, I could probably have surgery this late spring or early summer.
2. We have reason to believe that all the 2017 plans remove the exclusion. We're going to see if we can find a definite answer. Unfortunately my plan doesn't switch to the 2017 plan  until July. But if they are dropping the exclusion then my dad says there's no point in fighting it. Just wait. Makes me pretty upset though bc I can't submit the request until right before the plan changes if I want them to take into account the new plan. Which means I have to wait for the response before I can schedule the date, which means I won't even schedule something until July or August so depending on how busy she is, surgery could be WAY off.
3. We're going to try to see if there's any lawyers who will help us look over stuff, preferably for free bc we don't have the extra money for this, to see if there's any way to get around this exclusion. We're not sure how legal it is, particularly after January 1. But neither me nor my dad knows a lot about laws and stuff so we can't tell.

As for in/out of network, we're 90% sure we'll get the in network prices anyways bc she's still in the insurance's system even if she's supposed to be out, but we'll cross that bridge when we get to it.

[FTMax]

Awesome! I'm glad it went well.

Would it be possible for her to tentatively put you on her schedule for maybe August or September and then run insurance after July 1? All the folks I've used insurance with seem to want to get a pre-authorization 30-90 days in advance of surgery and not too long before. Maybe if you explain to her office the position you're in with insurance, they'd be willing to make an exception. Especially if you were open to putting a deposit down to secure the date (which you would presumably be reimbursed for when insurance pays out).

As far as legal help, you could get in touch with http://out2enroll.org/ They are insurance experts for the LGBT community and could likely give you a definitive answer about what to expect with your plan. As far as appealing the exclusion, you could consider contacting your state's bar association. I know mine offers an hour of free legal assistance per year or something like that.

[CursedFireDean]

Awesome! I'm glad it went well.

Would it be possible for her to tentatively put you on her schedule for maybe August or September and then run insurance after July 1? All the folks I've used insurance with seem to want to get a pre-authorization 30-90 days in advance of surgery and not too long before. Maybe if you explain to her office the position you're in with insurance, they'd be willing to make an exception. Especially if you were open to putting a deposit down to secure the date (which you would presumably be reimbursed for when insurance pays out).

As far as legal help, you could get in touch with http://out2enroll.org/ They are insurance experts for the LGBT community and could likely give you a definitive answer about what to expect with your plan. As far as appealing the exclusion, you could consider contacting your state's bar association. I know mine offers an hour of free legal assistance per year or something like that.

Thanks for all that info!

I did a buttload of research and ultimately it seems like I'm stuck with the exclusion until July, and it's DEFINITELY going away then. It's not THAT far away I just freaked out at first but now that I'm getting used to the idea, I can live with it. I just don't have the energy to do all that work to try to argue it. I'm still going to check out out2enroll though, that sounds like a good resource. And I am curious about whether my company would approve me if I tell them something like- You're going to cover the surgery one way or another. Whether it's now or in July, you're going to eventually cover it and I will keep submitting until you do. It will likely be more expensive in July-  the surgeon may increase her fees. So pay for it now or pay for it in 6 months at potentially higher cost to you- it's your decision.
I just don't have the $200 for MacPhee to submit the approval to insurance and risk a denial. I do think it's ridiculous that that costs $200 but if it'll save me $4000 then I guess it's fine. But I don't want to pay the $200 twice if I don't have to. But I'll talk to her office about this situation- if I get a denial and then my plan changes, if I have to pay for them to resubmit. 

I did start a youcaring fundraiser and I'm doing decently with it I think, and when I did the math, I think July/August is a reasonable expectation as far as raising the money for my copay and deductible. As long as I can manage to find a part time job from January to July, I should be able to get almost enough, and then hopefully the rest will come through my friends and family.

She's had problems in the past with patients constantly pushing dates around, so she requires a $500 deposit to schedule. Right now I'm at about $320 saved so I can't put it down now, but I think once I manage to get a part time job and I feel confident in my ability to save enough for my deductible and copay, I'll go ahead and schedule. I've been told that I should be able to submit the approval sometime in June and as long as it's clear that the surgery will be after July 1, they should use the new benefit plan in their decision. But I am gonna double check that when I get closer to the date. Really I think I'll drive over to her office sometime after Christmas and talk with her front desk lady- she seemed super nice and knew more about the insurance dealings.

If I do end up scheduling pretty far in advance, I'll probably shoot for August 3 It's my birthday so it would be a nice present to myself.