My Local City : Health records, billing, insurance, and legal documents in transgender medicine

//My Local City : Health records, billing, insurance, and legal documents in transgender medicine

– [presenter] welcome to the fifth and last creogmodule 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.

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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.

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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.

2018-07-12T06:37:44+00:00 July 12th, 2018|Categories: Discover Cities in My Online World|Tags: , |