As many of you may know, one of the things that told me I was on the right path with my transsexuality was that the insurance company would pay for my SRS. This is such an unusual position for an insurance company to make, I knew it must be fate.
I had verified this several times and with multiple people at the insurance company. The only real hitch was that since my surgeon was out of network, I would have to pay for the operation up front then be reimbursed for the procedure. Ok, no *big* deal, just arrange for a short term loan and then pay it off when the reimbursement check comes in.
Well after some scrambling, and finding out that it’s easier to borrow $5k than it is to borrow $16K, I ended up with a loan from one of the national credit card companies who arranged a line of credit for me. It’s a fixed term loan with an interest rate that is just a couple of points away from loan shark. Again, no real problem since all that would go away in just a few months anyway.
So I arranged for the operation and made the first few payments on the loan. It put a big dent in my disposable income, but I am one to keep my eye on the prize. Completing my transition is uppermost in my mind and felt this was a short term pain.
Now the insurance company put just three conditions on paying for my procedure. And they are:
1. Get a referral from the Primary Care Physician.
2. Have the referral approved by the medical group.
3. It must not be cosmetic surgery.
That seemed simple enough.
My PCP has been with me from the start of my process and had already agreed to write the referral, and the medical group is the main medical group for the LGBT community so I didn’t think that they would object, and, of course, having GRS is not cosmetic. It’s a medical necessity as listed in the DSM-IV for those patients diagnosed with GID.
Well, a few weeks ago I asked the doctor to start the process for the referral. He told me he would get right on it.
A few days later, I received a phone call from the clinic saying my referral had been denied!
I asked why, and the person at the clinic said that they didn’t know other than it was marked as “Not a Supported Benefit”.
I spent the next half of a day calling back and forth between the insurance company, the medical group, and the clinic to find out what went on.
What I found out was very enlightening. The referral was denied because cosmetic procedures are not allowed! As it turns out, the referral has to be written using the insurance company’s automated referral system. The automated referral system will only allow GRS to be entered as a cosmetic procedure!
Catch-22! You can't have a cosmetic procedure but the procedure can only be entered as cosmetic! This deceitful practice gave me a false sense of hope. And according to everyone in the loop none of it was their fault. No one was responsible for setting up the referral system that way, and no one could be found to find out why it was that way. Had I known that they would play these kind of games with my happiness and health I would have come up with alternative plans.
When I asked what recourse I had, the insurance company said that I could self pay… Thanks.
I asked what other options I had. They said that there was an appeals process. I could submit my reasons for opposing their denial and provide as much documentation as possible and they would consider a response. But I had only sixty days to file an appeal and they would respond within thirty days.
As you might expect, I was devastated! The loan I was expecting to pay off was now looking like a constant companion for the next eighty-four months!
I wasn’t going to let it get me down. At the minimum, none of these Machiavellian mind games would prevent me from having my GRS! Everything was already paid for. And since I had sixty days to respond, I wasn’t going to worry about it until I got back from Doylestown. I decided to sit back and enjoy the ride. I wasn’t going to let my frame of mind be twisted out of the near bliss I was feeling as I got closer to my surgery date.
I did, however start composing my appeal in my head and I contacted my therapists and doctors about the turn of events and asked them for a letter explaining why this surgery was not cosmetic. All of my “gender team” were very sympathetic and determined to do the very best they could for me.
I figured that once the letters came in I’d send the appeal through and worry about any other issues when I got back.
Certainly I was concerned, but I wasn’t going to let it stop me.
A few days after that, I started receiving letters. Two were not in my hand, however. One of my therapists insisted that they would send the letter directly to the appeals board. So I sent the information on where to send it, and I guess it was sent. My PCP happened to be on vacation and said that they would have it ready by time they returned from vacation.
Then a few days ago I got another phone call from the clinic. My denial had been rescinded!
Naturally I was over the moon with happiness! There was no explanation other than the denial had been changed to approved and was approved by the medical director.
I had not sent in my appeal yet so I was curious as to why the reversal came through. I initially surmised that my therapist had convinced them to change their minds based solely upon her appeal! If that was the case I was mightily impressed!
The next day however, I was scheduled to have my final blood tests done at the clinic. When I got there, I happened to run into my doctor. We hugged and I asked if he had heard about my appeal. He said no. I told him that his nurse had told me, so he should have checked with him. I told him what the nurse had told me and a smile lit his face.
What my doctor said was that he had contacted the insurance representative directly and he spent over an hour discussing my case with her. He explained why it was a medical necessity for me to have this procedure. He also submitted over THREE HUNDRED PAGES OF DOCUMENTATION in support of his position! In the eyes of the insurance company, unless a procedure will directly save a life, it is considered “cosmetic”. This of course is not the way the medical community sees things.
I am seriously indebted to my doctor. He went way beyond the extra mile for me. And because of his effort my last hurdle has been overcome.
-Sandy(enjoying the ride)
I had verified this several times and with multiple people at the insurance company. The only real hitch was that since my surgeon was out of network, I would have to pay for the operation up front then be reimbursed for the procedure. Ok, no *big* deal, just arrange for a short term loan and then pay it off when the reimbursement check comes in.
Well after some scrambling, and finding out that it’s easier to borrow $5k than it is to borrow $16K, I ended up with a loan from one of the national credit card companies who arranged a line of credit for me. It’s a fixed term loan with an interest rate that is just a couple of points away from loan shark. Again, no real problem since all that would go away in just a few months anyway.
So I arranged for the operation and made the first few payments on the loan. It put a big dent in my disposable income, but I am one to keep my eye on the prize. Completing my transition is uppermost in my mind and felt this was a short term pain.
Now the insurance company put just three conditions on paying for my procedure. And they are:
1. Get a referral from the Primary Care Physician.
2. Have the referral approved by the medical group.
3. It must not be cosmetic surgery.
That seemed simple enough.
My PCP has been with me from the start of my process and had already agreed to write the referral, and the medical group is the main medical group for the LGBT community so I didn’t think that they would object, and, of course, having GRS is not cosmetic. It’s a medical necessity as listed in the DSM-IV for those patients diagnosed with GID.
Well, a few weeks ago I asked the doctor to start the process for the referral. He told me he would get right on it.
A few days later, I received a phone call from the clinic saying my referral had been denied!
I asked why, and the person at the clinic said that they didn’t know other than it was marked as “Not a Supported Benefit”.
I spent the next half of a day calling back and forth between the insurance company, the medical group, and the clinic to find out what went on.
What I found out was very enlightening. The referral was denied because cosmetic procedures are not allowed! As it turns out, the referral has to be written using the insurance company’s automated referral system. The automated referral system will only allow GRS to be entered as a cosmetic procedure!
Catch-22! You can't have a cosmetic procedure but the procedure can only be entered as cosmetic! This deceitful practice gave me a false sense of hope. And according to everyone in the loop none of it was their fault. No one was responsible for setting up the referral system that way, and no one could be found to find out why it was that way. Had I known that they would play these kind of games with my happiness and health I would have come up with alternative plans.
When I asked what recourse I had, the insurance company said that I could self pay… Thanks.
I asked what other options I had. They said that there was an appeals process. I could submit my reasons for opposing their denial and provide as much documentation as possible and they would consider a response. But I had only sixty days to file an appeal and they would respond within thirty days.
As you might expect, I was devastated! The loan I was expecting to pay off was now looking like a constant companion for the next eighty-four months!
I wasn’t going to let it get me down. At the minimum, none of these Machiavellian mind games would prevent me from having my GRS! Everything was already paid for. And since I had sixty days to respond, I wasn’t going to worry about it until I got back from Doylestown. I decided to sit back and enjoy the ride. I wasn’t going to let my frame of mind be twisted out of the near bliss I was feeling as I got closer to my surgery date.
I did, however start composing my appeal in my head and I contacted my therapists and doctors about the turn of events and asked them for a letter explaining why this surgery was not cosmetic. All of my “gender team” were very sympathetic and determined to do the very best they could for me.
I figured that once the letters came in I’d send the appeal through and worry about any other issues when I got back.
Certainly I was concerned, but I wasn’t going to let it stop me.
A few days after that, I started receiving letters. Two were not in my hand, however. One of my therapists insisted that they would send the letter directly to the appeals board. So I sent the information on where to send it, and I guess it was sent. My PCP happened to be on vacation and said that they would have it ready by time they returned from vacation.
Then a few days ago I got another phone call from the clinic. My denial had been rescinded!
Naturally I was over the moon with happiness! There was no explanation other than the denial had been changed to approved and was approved by the medical director.
I had not sent in my appeal yet so I was curious as to why the reversal came through. I initially surmised that my therapist had convinced them to change their minds based solely upon her appeal! If that was the case I was mightily impressed!
The next day however, I was scheduled to have my final blood tests done at the clinic. When I got there, I happened to run into my doctor. We hugged and I asked if he had heard about my appeal. He said no. I told him that his nurse had told me, so he should have checked with him. I told him what the nurse had told me and a smile lit his face.
What my doctor said was that he had contacted the insurance representative directly and he spent over an hour discussing my case with her. He explained why it was a medical necessity for me to have this procedure. He also submitted over THREE HUNDRED PAGES OF DOCUMENTATION in support of his position! In the eyes of the insurance company, unless a procedure will directly save a life, it is considered “cosmetic”. This of course is not the way the medical community sees things.
I am seriously indebted to my doctor. He went way beyond the extra mile for me. And because of his effort my last hurdle has been overcome.
-Sandy(enjoying the ride)
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