Content Note: we will be using medical and anatomical terms a few times while we talk about procedures, policies, payments, and appeals. This content may be upsetting for some readers. We use these terms not to cause distress but to help readers talk to insurance efficiently.
Welcome back to the QueerDoc blog! This month, our theme is insurance, and today we’re diving into some of the intricacies of procedures, policies, payments, and appeals. We at QueerDoc would love to see single payer insurance in the USA sooner rather than later, but until we have healthcare for all, we are working to support and create access to gender affirming care. We’ve chatted about your healthcare rights and how to find out what your plan covers, changes coming to state-regulated insurance in Washington in 2022, and this week, we’d like to share some tips for talking to your insurance about your care.
If you need to call your insurance, some preparation beforehand may help you navigate the discussion. We provide some handouts on our Gender Affirming Surgery resource page and our dictionary and code resource page defines some of the terms you may need. Today’s blog is intended to provide further support for your conversations.
Tips For Talking To Insurance: Procedures, Policies, Payments, and Appeals:
In medical billing, procedures are identified and described by CPT Codes.
CPT Code: A 5-digit code used to represent a specific medical procedure.
An example of a CPT code:
54690 – LAPAROSCOPY, SURGICAL; ORCHIECTOMY (orchi using a laparoscope) A laparoscope is a slender tool with a camera at the tip. The camera is placed inside the body during the surgery and allows the surgeon to see and do the procedure using smaller incisions. Also known as “minimally invasive surgery.”
All procedures must be matched to a diagnosis code. This is done with ICD-10 diagnosis codes.
You may see the code F64.9, Gender identity disorder, unspecified used in your records. Some providers use the code E34.9, Endocrine disorder, unspecified. E34.9 can sometimes be used for labs, prescriptions, and visits. Using stigmatizing words like “disorder” in an official diagnosis to be able to access care is something that many patients and providers disagree with, and are working to change. However, no insurance company that we know of will accept E34.9 in claims for surgery. Some insurance companies require F64.9 in prior approval paperwork for prescriptions. If you have concerns about F64.9 appearing in your medical records, please talk to your provider.
Do you need to know if your care will be covered?
You may need to reference the following terms:
Covered benefit: will insurance cover this procedure?
Excluded care: these are services that your insurance will not pay for. Often, insurance plans exclude non-necessary (may be called “elective”) procedures. If they exclude all gender affirming healthcare, this may be illegal.
The National Center for Transgender Equality has created an excellent guide to your healthcare rights . We’ve referenced it a couple of times this month. If you think that your insurance plan is discriminatory, NCTE can help you find resources for filing a report.
In-network and Out-of-network: your in-network list is the providers that your insurance company has legal agreements with. Getting care from an out-of-network provider may cost more. An in-network provider may also be called a preferred provider.
Are there things that your insurance requires before they’ll cover a procedure?
The procedure you want may need a referral. This is when your primary care provider or hormone prescriber writes an order for you to see a specialist or get specific services.
Your insurance may want preauthorization or prior approval before they’ll agree to pay for a service. For gender affirming procedures, insurance companies often want documentation that you have taken hormones (or that you cannot take hormones,) and that a mental health provider who is knowledgeable about gender has spoken to you about your gender, and has seen you within a certain amount of time. Your insurance may require that a specific diagnosis code (for example, F64.9,) is used for your procedure, or only cover specific procedures.
You may want to ask about hospitalization coverage and durable medical equipment (DME.) Your insurance may have a limit on how many days of care they’ll pay for in a hospital and what they’ll pay for any equipment you’ll need after your surgery (such as dilators or compression vests.)
You may need to ask about your deductible, your coinsurance, your out-of-pocket or maximum limit, and if there are any non-covered fees for surgical procedures.
Your deductible is the amount of money you must pay each year before insurance starts to pay for your care.
After your deductible, you and your insurance split the cost of the procedure. This is your coinsurance. If your insurance pays 80% of the allowed amount, your coinsurance is 20%.
Allowed amount is the maximum amount of money your provider will be paid by YOUR INSURANCE for the procedure. This may be different from the amount that is billed to your insurance by your provider.
Your out-of-pocket limit is the total amount of money you are responsible for in a year. After you reach your out-of-pocket limit, insurance pays the full cost of your care for the rest of the year.
Surgical fees: your surgeon or surgery center may charge you fees that are not paid for by your insurance. Ask about them so that you don’t get a surprise anesthesiology bill!
Transportation: Medicaid plans often pay for transportation if needed. Get that ride paid for if you have to spend money on getting to/from your surgery!
Appeals: what if they say no?
If your insurance says “No, we won’t pay for that,” you can appeal. An appeal is a request for them to review that decision.
One appeal tool is a peer to peer. In a peer to peer, your doctor talks directly with your insurance to explain why your procedure is medically necessary and, therefore, should be covered.
Your insurance may undertake an utilization review. This is a process designed to figure out if a plan of care is (or was) medically necessary, according to evidence-based guidelines, and/or appropriate and efficient.
If you are not able to get information from your insurance company, or if you would like to appeal a decision, consider asking your insurance what their appeal process is and if they have patient advocates on staff. Patient advocates can help you understand your rights and options and help you communicate with your doctors and/or insurance company.
Navigating your insurance and the appeal process can be hard, confusing work. There are many groups that can help. We’ll discuss resources for talking with your insurance next week (including us!)