An Episode to the Epilogue

An Episode to the Epilogue

Previously I have posted that I have completed my transition so then too I would have completed my postings to my blog, “Sandy’s Transition”.

Ah were that the case. The last few weeks have left me stressed out, anxious, and depressed as ever I have been in my life.

If you have been following my story, you will have read that I was one of the fortunate few whose insurance coverage actually did cover not only my orchiectomy, but also my Gender Confirmation Surgery as well.

You may have also read that while it was “covered” it wasn’t *covered*. Something to do with my insurance company (Blue Cross/Blue Shield HMO of Illinois) not covering cosmetic surgeries, but the only way to list my referral for GCS was as cosmetic. Catch-22. (And why in the world would you list as “cosmetic” something that good girls don’t go around showing off is beyond me!!!)

My doctor, surgeon, and therapists all sent in recommendations that this surgery wasn’t cosmetic, but was a life saving operation. And only after my doctor talked to the insurance company directly and submitting over three hundred pages of notes and documentation, that the insurance company relented and approved my referral.

But since the operation was out of network, I had to pay for it upfront, then, I was assured, I would be reimbursed. I proceeded to take out a loan with near loan shark rates assuming that the interest rate wouldn’t matter that much since I would be paying it off in a reasonably short period of time after I received my reimbursement.

Ok, let’s fast forward through my trip, surgery, and return. It’s posted on the blog for those who want to relive those wonderful days with me. (I still recall the moment my plane took off for Philadelphia with a wistful fondness.)

Ok, back home and now trying to put my life back on track after a two year process to change every part of my being. One of the details was to start submitting the paperwork to the insurance company to get my reimbursement.

I contacted the person at BCBS about submitting the required information. I was told that there was a form on the website and that I should fill it out and submit that and the relevant invoices to the insurance company.

I did that and didn’t hear anything for a few weeks. I called and after going through the usual mind numbing phone menu and being put on hold so long that I actually started liking the musak that was playing in the background and could recite all the phone-on-hold commercials by heart… backward.

I finally talked with someone and they said that the documentation that was submitted was not complete. They required an itemized invoice including standardized procedural codes and diagnostics.

Ok.

I called the surgeons office and contacted someone from admin. Fortunately the also had been contacted by the insurance company and they had requested the same things. But I would have to contact the hospital to get that information as well as the anesthesiologist.

Ok.

I worked through this process over the next few weeks. Regularly contacting the insurance people as well as the billing and admin people at the surgeon’s office, the hospital and the anesthesiologist.

I then receive a note from BCBS stating that my claim wasn’t covered because they do not cover GCS.

Arrgghh!!! Scream!! Cry!!!

I contact the insurance people and they tell me that the never covered that surgery and even though I had a proper referral it wasn’t BCBS’s responsibility to pay it. I was welcome to contact the medical group to see if they would pay for it, but their responsibility was at an end.

Arrgghh!!! Scream!! Cry!!! Arrgghh!!! Scream!! Cry!!!

After I dried my eyes, actually the tears ran out. I contacted the medical group.

I then had to go through the exact same submission of documentation that I went through with BCBS.

Following that, I was told that even though I submitted the proper information I would not be reimbursed. The medical group only reimburses the hospital and they should have submitted the information directly to them in the first place.

With a calm and demeanor rivaling that of Job, I explained to this person that I had been told that I HAD to pay for it out of pocket since it was out of network and that I was SUPPOSED to get reimbursed! I had been told that by several people at BCBS (accent on the BS!), the medical group, and my physicians office!

This person again told me that the policy was only to reimburse the hospital after they submitted the proper documentation. That person refused to even look at my referral.

At that point, I had a proper and satisfying meltdown. I yelled at them that they were an idiot and I wanted to speak with their supervisor!

After a few minutes I was put in contact with the supervisor and I explained the situation again.

This time, the person actually reviewed the case and said that actually everything seemed in order. My referral was proper, and my documentation was complete. She thought it was just a matter of examining the data and making a determination who would pay what.

I started sobbing on the phone. I was so relieved to get even that response that I lost all control. The lady said that she would review the information and would be getting back to me. She even gave me her direct line so that I wouldn’t get ear calluses wading through the phone menu.

I thanked her profusely and hung up, feeling more relieved than I had in several weeks.

A few days later, the lady from the medical group did call me back and said that she had to contact the surgeon, hospital, and anesthesiologist but she had all the information she needed. She said that there would be two checks sent out. One would come from the medical group, which would pay for the surgeon, and the other would come from BCBS who would be paying for the hospital stay and the anesthesia.

By this time my spirits were lifting considerably.

A few days following that, I did receive a check from the medical group. After waiting another few days, I still had not received the check from BCBS. I was starting to get worried that they would renege on their agreement. I called the lady at the medical group back and asked if she had heard anything. She said no but would check into it.

No sooner had I hung up from her, I got a call from the billing department at the hospital where I stayed.

She told me that BCBS had sent them a check for my bill. She said that she would personally walk the check over to Accounts Payable and have them cut me a check that very day!

I was over joyed!

However after several more days I still had not received the check. I call the lady at the hospital back and asked if she had heard anything. She checked with AP and the said that they had FedEx’d the check and it was recorded as delivered!!! (A signature had not been asked for)

Arrgghh!!! Scream!! Cry!!! Arrgghh!!! Scream!! Cry!!! Arrgghh!!! Scream!! Cry!!!

In all my years of using FedEx and other services, I had never had a lost item. Why did it have to happen with this one!!!! I felt that I was being toyed with by the fates. It seemed that I had to keep leaping to get to my goal, but it would be pulled out of my reach at the last moment. This last twist to this really had me undone.

I told them that I had not received it and that they should put a stop on the check and could they send out another? (Pretty please???)

The nice lady and her partner at AP said that they would overnight the check to me and require a signature.

The next morning, finally, the replacement check arrived. I was so relieved!

I just deposited it this morning, and bring to a close this last major chapter of my transition from man to woman.

It has been a very short time for me since I started down the path to confirm my true nature. I have been truly blessed by the way my transition has gone. My family loves me, I was not discriminated at work, and the financial needs have been taken care of. Though I do feel that I have had to mortgaged my future to save my present. But in all likelihood I would have probably not lived long enough to enjoy my future were I not to transition.

Just this evening I was sitting at the dining room table with Pat and I was feeling very content. And I looked down at myself then at Pat, and I asked myself what the big deal was. I was finally as much of a woman as far as medical science could make me and I felt so normal that I couldn’t remember what the crisis was when I had male genitals.

Then I thought about having a penis again and I was overcome with revulsion. I guess I really was a transsexual. So many times we wonder if we have made the right decision to transition. I now know I made the right decision!

-Sandy

Overcoming the last hurdle

Overcoming the last hurdle

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)