- [Presenter] Welcome to the fifth and last CREOG
module on caring for transgender and gender
nonconforming patients for the obstetrician-gynecologist.
These modules were created with the support of
the CREOG Empower Award and with the
support of the University of Michigan.
Module five, administrative considerations.
Once you've mastered the clinical and social elements
of providing care to transgender and gender
nonconforming people, the messy business of
administration emerges as the next hurdle.
Providers and office staff should be prepared to
advocate for patients in order to ensure access to and
coverage for preventative care, transition-related care,
and any other reproductive healthcare needed.
Module objectives.
This modules describes the challenges and remedies
in health administration systems which revolve around
the interfaces between health records,
billing systems, and insurance claim processing.
At the end of this module we also describe the role that
providers play in helping transgender patients update their
identity documents to reflect their gender identities.
Self-assessment.
One, when billing insurance for transition-related
care the best practice is to submit claims in the
usual manner and wait to see if any problems arise.
True or false?
Two, in order to change their gender marker on
federal documents, a transgender person must provide
evidence of gender reassignment surgery.
True or false?
Insurance claim processing.
When a provider's office sends a bill to an insurer,
an automated claim processing program checks to see if
the plan excludes coverage for each diagnosis code,
ICD-10, the plan excludes cover for each procedure code,
CPT, the submitted diagnosis and procedures codes
correspond with each other, and the submitted
diagnosis and procedure codes correspond with basic
patient information, including the gender marker on file.
For example, a diagnosis of streptococcal laryngitis
with procedure code for toe amputation would fail the test.
Insurance claim processing.
If the bill passes these checks,
the claim is routed to payment processing,
from where the insurer will send payment and
explanation of benefits to the provider's office,
and then explanation of benefits, or EOB, to the patient.
If the bill fails any of the checks,
the insurer does not issue payment,
but does provide an EOB to the provider and patient
explaining why no payment has been issued.
In this case, we commonly refer to
the EOB as a claim denial.
Insurance claim processing.
Where a transgender person is concerned,
normal treatments often cause the
bill to fail the automated test.
Insurance claim processing, anatomy specific care.
Let's start with anatomy specific care.
For example, a transgender man has an M on file,
and the bill includes a CPT for a pap test.
A transgender woman has an F on file,
and the bill includes the CPT for a prostate exam.
A transgender woman has an M on file,
and the bill includes a CPT for a mammogram.
In each of these cases, the insurer is
likely to issue a claim denial.
When this happens, the provider's office should respond
in writing within the stated time limit explaining that
the care provided was appropriate to anatomy present.
Typically, this is enough to reverse the claim denial.
If you have never submitted a transgender medicine
related claim before, or if you have never
submitted one with a particular insurer,
the best practice is always to submit a preauthorization
before the patient has incurred any costs.
Now let's look at transition-related care specifically.
Where transition-related care is concerned,
insurance challenges can be more complex.
Let's zoom out to look at the context in which
public policy addresses transgender medicine
to understand the big picture.
Until very recently, it was legal nationwide for
insurers to deny coverage for transition-related care,
or any care provided to a transgender person that the
insurer claimed to be related to their transgender status,
no matter how erroneous the claim.
Insurance exclusions, transition-related care.
As a result, the industry standard was to include
a section in the excluded benefits section of each
insurance plan listing gender identity disorder,
gender dysphoria, transgender status, sex change,
and or my personal favorite, sex transformation,
and all associated treatments as excluded from coverage.
These blanket exclusions are coded into automatic
claims processing programs to deny any claim with
a diagnosis code for gender identity disorder or
gender dysphoria or transexualism.
In 2012, California became the first state to issue
regulations to insurers stating that these blanket
exclusions constitute unlawful sex discrimination.
Since then, 17 other states and the District of Columbia
have issued similar guidance to insurers in their states.
In some states, nondiscrimination guidance applies
to private, as well as public, insurance.
For example, Medicaid or local safety
net programs where they exist.
In some states, guidance only applies to private insurance.
In some states, there is parallel
guidance for public insurance.
The specificity and limits of the nondiscrimination
guidance in each state varies.
Federal protections.
The nondiscrimination section of the Affordable
Care Act, Section 1557, was widely interpreted to
ban blanket exclusions of transition-related care
nationwide since it became law in 2010.
In September 2016, the Department of Health and
Human Services issued specific regulations to
interpret and enforce Section 1557.
These regulations detailed the types of insurer
practices that constituted unlawful sex discrimination
along with the consequences for discriminating.
According to these regulations,
gender identity based discrimination or
exclusions constitute unlawful sex discrimination.
However, the portions of the ACA Section 1557 relating
to transition-related care as well as coverage for
abortions were challenged in federal court,
and the current federal administration
declined to defend the law.
As of February 2018, the law and regulations stand
as written, but enforcement at the
federal level remains unclear.
When appealing insurance claim denials,
it may still be useful to cite ACA Section 1557.
However, state-specific nondiscrimination guidance
continues to stand in California, Colorado, Connecticut,
Delaware, the District of Columbia, Illinois,
Maryland, Massachusetts, Michigan, Minnesota,
Montana, New Jersey, New York, Nevada, Oregon,
Pennsylvania, Rhode Island, Vermont, and Washington.
Insurance claim processing, denials.
While some insurers and insurance policies cover
transition-related care and will approve claims for
transition-related care, others may deny the claim.
In many cases, automated claims processing systems
will issue a denial even when the individual's
policy includes coverage for transition-related care.
Insurance claim processing, remedy steps one.
If an insurer denies a claim for transition-related care,
or a plan based in a jurisdiction with a standing
nondiscrimination policy, the remedy steps are,
one, respond in writing within the specified time limits
stating that the patient has been diagnosed with
gender dysphoria and that the treatment is
appropriate as described by leading professional
associations including the AMA and ACOG,
and refer to the state guidance, usually called a bulletin.
In the vast majority of cases, a written appeal to the
initial denial is sufficient to reverse the denial.
Insurance claim processing, remedy steps two.
If the insurer rejects your initial appeal of the denial,
file a complain with the state agency
in charge of regulating insurance.
Usually, the agency offers an Independent Medical
Review of insurer claim denials.
Pay close attention to time limits,
usually 180 days from the denial date,
but sometimes shorter.
The vast majority of cases sent through a
state's IMR reverse insurer denials.
Insurance claim processing, additional options.
If the plan is a Medicaid plan, there may be
additional options for appealing first level denials.
Check with legal aid societies in your area for details,
as these vary state by state and sometimes county by county.
If the plan is a Medicare plan, note that in 2014
the Department of Health and Human Services
struck down Medicare's ban on coverage for
gender reassignment surgery, but has not issued a
replacement policy detailing procedures for coverage.
Medicare claims for transition-related surgeries
are reviewed on a case-by-case basis,
but cannot be preauthorized.
Medicare coverage for hormone therapy is well-accepted.
Insurance claim processing, best practice.
The best practice for providers is to
submit preauthorization claims for
any transition-related treatment.
This way, any appeals needed can be done before
the patient has incurred any costs.
Now let's look at identity documents.
For many transgender people, having legal documentation
that accurately reflects their gender,
can be of vital importance.
For example, having an incorrect gender marker
on a passport can cause significant
problems with airport security.
Having an incorrect gender marker on a drivers license
can cause difficulties in a host of legal encounters,
place a barrier to voting, and put people at risk of
outing or exposure of their trans identity in
the multitude of daily uses of government-issued ID.
Changing the name and gender marker on ID
can be a complex and confusing process,
and medical providers should be prepared to
provide letters of support as a routine matter.
No medical documentation is required for name changes,
but may be required for gender
marker changes with some agencies.
In most cases, a court order is required
to change a person's legal name.
The court order can then be used to update the name
on file with federal, state, and local agencies.
No medical documentation is required for name changes.
To change the gender marker with federal agencies,
including passports, Social Security Administration,
and U.S. Customs and Immigration,
transgender people are required to submit a signed
letter from a physician stating that they have
administered appropriate clinical treatment
for transition to the new gender.
It is not necessary to include specific treatment details.
Identity documents continued.
A step-by-step guide to changing federal ID,
including checklists and sample physician letters,
is available from Transgender Law Center at
transgenderlawcenter.org/resources/id/id-please.
Identity documents continued.
The process of changing one's gender marker on
state-issued identification varies from state to state.
In some, but not most, states,
gender reassignment surgery is the only
acceptable form of clinical treatment.
A state-by-state guide is available from the
National Center for Transgender Equality here,
transequality.org/documents.
Summary.
Administrative aspects of care for
transgender patients can be confusing.
Like anything else, repetition is key to mastery.
Submitting preauthorizations with insurers can
save stress, time, and money for patients and providers.
Providers play a key role in helping transgender
patients integrate into legal systems of recognition
through identity document changes.
Self-assessment.
One, when billing insurance for transition-related care,
the best practice is to submit claims in the usual
manner and wait to see if any problems arise.
False, the best practice is to preauthorize any treatment.
Two, in order to change their gender marker on
federal documents, a transgender person must provide
evidence of gender reassignment surgery.
False, no specific medical treatment is required
to change the gender marker on federal documents.
Insurance appeals, more resources.
One, statements from professional associations
endorsing treatment for gender dysphoria
is available from Lambda Legal at this link.
Two, state insurance bulletins can be found online
by Googling the name of the state
insurance transgender bulletin.
Here is an example for the state of Michigan.
Three, a detailed map and table tracking the status
of transgender health nondiscrimination policies
at the state levels is available from the
Movement Advancement Project, available at this link.
Four, a video guide to appealing transgender insurance
denials from Transcend Legal is available at this link.
Five, the National Center for Transgender Equality
has provided an FAQ about the Affordable Care Act
Section 1557, the nondiscrimination section.
Identity documents, more resources.
Transgender Law Center's ID, PLease,
and the National Center for Transgender
Equality's ID Documents Center.
Thank you.
This concludes module five.