Insurance 101: Part 2

Welcome back to our blog! We hope you enjoyed Insurance 101 – Part 1, which introduced us to some basic insurance terminology. Now that we have covered the basics, today we will talk about insurance and surgeries.

 

Current Procedural Terminology:

This is also known as a CPT code. It is a medical code set that is used to report medical, surgical, and diagnostic procedures and services to entities such as physicians, health insurance companies, and accreditation organizations. Essentially, it is a set of numbers and sometimes letters that providers and healthcare facilities use to bill your insurance company. Each procedure, medication, or order has a specific CPT code.

For transgender patients treated by Dr. Webb, the most common CPT codes we use are:

  • 58570 – This is a laparoscopic total hysterectomy, also known as LTH
    • This is removal of the uterus and the cervix
  • 58571 – Laparoscopic total hysterectomy and bilateral salpingo oophorectomy, also known as LTH with BSO
    • This is removal of the uterus, cervix, both fallopian tubes, and both ovaries
  • 57110 – Vaginectomy
    • In this procedure, the vaginal mucosa is removed (Look out for a future blog on this subject!)

 

INTERNATIONAL CLASSIFICATION OF DISEASE:

More commonly referred to as an ICD code. ICD codes are updated by the World Health Organization (WHO) every few years, and we are currently using ICD-10 codes. ICD codes are a classification of diseases and health conditions in the medical field.

 

Clinical Information for Gender Identity Disorder: A disorder characterized by a strong and persistent cross-gender identification (such as stating the desire to be the other gender or frequently passing as the other gender) coupled with persistent discomfort with his or her gender (manifested in adults, for example, as a preoccupation with altering primary and secondary gender characteristics through hormonal manipulation or surgery.)

The ICD-10 codes related to Gender Identity are:

  • F64.0 – Transsexualism (As defined by the World Health Organization)
    • WHO definition: “A desire to live and be accepted as a member of the opposite sex, usually accompanied by a sense of discomfort with, or inappropriateness of, one’s anatomic sex, and a wish to have surgery and hormonal treatment to make one’s body as congruent as possible with one’s preferred sex.”1
  • F64.1 – Dual-role transvestism
    • WHO definition: “The wearing of clothes of the opposite sex for part of the individual’s existence in order to enjoy the temporary experience of membership of the opposite sex, but without any desire for a more permanent sex change or associated surgical reassignment, and without sexual excitement accompanying the cross-dressing.” 1
  • F64.2 – Gender identity disorder of childhood
    • WHO definition: “A disorder, usually first manifest during early childhood (and always well before puberty), characterized by a persistent and intense distress about assigned sex, together with a desire to be (or insistence that one is) of the other sex. There is a persistent preoccupation with the dress and activities of the opposite sex and repudiation of the individual’s own sex. The diagnosis requires a profound disturbance of the normal gender identity; mere tomboyishness in girls or girlish behavior in boys is not sufficient.” 1
  • F64.8 – Other gender identity disorders
  • F64.9 – Gender identity disorder, unspecified

 

PRIOR AUTHORIZATION:

Also known as pre-certification. Your physician must obtain prior authorization from your health care provider before prescribing a specific medication for you or to performing a particular operation. Without this prior approval, your health insurance provider may not provide coverage, or pay for, your medication or operation, leaving you to cover some, or all, of the costs out of pocket.

 

Why Do Health Insurers Require Prior Authorization?

There are several reasons that a health insurance provider requires prior authorization.

Your health insurance company uses a prior authorization requirement as a way of keeping health care costs in check. It wants to make sure that:

  • The service or drug you’re requesting is truly medically necessary.
  • The service or drug follows up-to-date recommendations for the medical problem you’re dealing with.
  • The drug is the most economical treatment option available for your condition. For example, Drug C (cheap) and Drug E (expensive) both treat your condition. If your doctor prescribes Drug E, your health plan may want to know why Drug C won’t work just as well. If you can show that Drug E is a better option, it may be pre-authorized. If there’s no medical reason why Drug E was chosen over the cheaper Drug C, your health plan may refuse to authorize Drug E.
  • The service isn’t being duplicated. This is a concern when multiple specialists are involved in your care. For example, your lung doctor may order a chest CT scan, not realizing that, just two weeks ago, you had a chest CT ordered by your cancer doctor. In this case, your insurer won’t pre-authorize the second scan until it makes sure that your lung doctor has seen the scan you had two weeks ago and believes an additional scan is necessary.
  • An ongoing or recurrent service is actually helping you. For example, if you’ve been having physical therapy for three months and you’re requesting authorization for another three months, is the physical therapy actually helping? If you’re making slow, measurable progress, the additional three months may well be pre-authorized. If you’re not making any progress at all, or if the PT is actually making you feel worse, your health plan might not authorize any further PT sessions until it speaks with your physician to better understand why he or she thinks another three months of PT will help you.

In effect, a pre-authorization requirement is a way of rationing health care. Your health plan is rationing paid access to expensive drugs and services, making sure the only people who get these drugs or services are the people for whom the drug or service is appropriate.

If you are planning your initial consult with Dr. Webb and would like to know if your insurance will cover hormone replacement therapy or lower surgery, you can use the information provided in this blog to find out. Call your insurance company and choose the option for coverage and benefits. Sometimes you will speak with an agent and you can provide him/her with the CPT and ICD-10 codes we listed above. The agent should be able to tell you if the procedure(s) is a covered benefit and if there are any exclusions or prior authorization requirements. You also want to make sure there are no exclusions for Gender Identity Disorder so make sure you ask the agent about this.

The insurance agent will likely have limited or no information about pricing for the procedures, but that is something we will cover after your initial consult when you meet with me, Kim. We hope this helps you prepare for your consult, please comment below with any suggestions or questions!

 

References

  1. The World Health Organization. http://apps.who.int/classifications/icd10/browse/2016/en#!/F64.0

 

What should I bring to my first visit with the FTM surgeon?

You will schedule an initial consultation with Dr. Webb in his Scottsdale office to discuss your needs. This visit may just be about starting hormone therapy if you have just begun the transition appointment, or it may be a surgical consult if you have already been on hormone therapy and are ready to begin reassignment surgery.

At this initial appointment:

  • You should arrive about 30 minutes prior to your appointment time so you can complete your registration and paperwork before seeing me. You will fill out paperwork that will include a list of your past medical history, prior surgeries, your current health conditions, any medications you are taking and any drug allergies you have. If you are taking multiple medications, it is strongly encouraged that you bring a current list that includes the names and dosages for everything you are taking. Providing a complete medical history and medication list helps us determine if any pre-operative clearance is needed and helps us schedule your surgery faster and more efficiently.

 

  • You will also complete a HIPAA privacy notice form and a financial policy agreement. You can download the forms on our website or we can mail/email the paperwork to you if you prefer to fill it out ahead of time. We have copies of all this paperwork at the office if you prefer to fill it out when you arrive at the office.

 

  • You will also need a note from your counselor in support of your surgery, or in support of beginning hormone therapy. Your doctor can fax the letter to my office at 480-425-8701. It is best to have the letter sent to my office about a week prior to your appointment to ensure we have received it in time for your visit.

 

  • If you have seen another transgender surgeon and have a future surgery planned, you should bring a letter from that surgeon(s) so that I am aware of the surgery you have planned. This helps me determine how to proceed with surgery and/or treatment that will make it easier for your doctor and any future procedures.

 

  • Bring a copy of your current insurance card and your driver’s license. We will scan copies of both cards for billing purposes. It is very important to inform my office of any changes to your insurance and/or contact information so we can provide you with accurate information when checking your surgical benefits.

 

 

What should I consider when looking for an FTM surgeon?

Picking a surgeon to perform your lower surgery can be challenging and it is very important to do your research before selecting a surgeon. You should choose a surgeon with at least 10 years of experience performing lower surgeries. The surgeon’s surgical training is also extremely important. Many gynecologists may perform the surgery, but very few have the expertise and reputation that is earned from years of experience performing the surgeries on transgender patients.

It is optimal to find a surgeon that is sensitive and aware of the specific needs of a female to male transgender patient. It is best to also have staff at the surgeon’s office that are available for questions and to help you schedule and prepare for your surgery. You also want to select a surgeon and surgical team that can work with your transgender surgeon that may be performing other surgeries at a later date.

You should also find out some information about where the surgeon operates and has privileges. Make sure that the surgeon is affiliated with a credentialed hospital that is able to provide overnight care for your hysterectomy and vaginectomy.

Also, inquire about the post-operative care the surgeon offers and if the surgeon will be available to you after your surgery, while you are recovering. All these criteria will help ensure you get a skilled surgeon that is able to achieve a successful surgery with minimal complications during your recovery period.

Why should I come to Scottsdale and choose Dr. Webb as your surgeon?

  • Webb has more experience performing the laparoscopic hysterectomy and vaginectomy procedure than anyone else in the United States. He also has more experience doing these procedures together than anyone else in the world.
  • Webb’s procedure has a lower complication rate.
  • Webb has an excellent, experienced team that he works with to perform the hysterectomy and vaginectomy. They have many years of experience working together and they use the most advanced equipment. No other doctors outside of this team are necessary for this procedure, so costs are lower.
  • Webb and his team will take care of you from the initial consult all the way up until you are ready to return home. They will provide you with personalized service and a warm, friendly atmosphere, from the Surgical Center and at his office.
  • You will meet with Dr. Webb before the surgery to answer all your questions and address any concerns you may have about the procedure. He will also have you schedule a post-op visit so he can see you before you leave town, to ensure you are doing well with your recovery process.

If you have any other questions or comments, feel free to leave a comment below! You can also contact Kim, who can be reached by phone at 480-291-6348, or by email.

 

 

Insurance 101 Part 1: Will Insurance Cover FTM Surgery?

The insurance world can be a little confusing, especially if you are not familiar with the frequently used terminology. This blog may help you understand your insurance coverage a little better and help you be a little more prepared should you ever need to contact your insurance company to ask about coverage.

It is always very important to understand your insurance plan and what your premiums pay for. I am going to cover some very common terms that you have probably heard or read when you signed up for your policy.

 COPAY:

A copay is a set amount that the insured (that’s you) pays for certain services. For example, you may pay a $20 copay every time you visit your primary care doctor’s office, or you pay a $50 copay every time you see a specialist. Copays do not count towards your deductible and you typically still have to pay a copay even after your deductible has been met.

DEDUCTIBLES:

A deductible is an amount that you as a policyholder must pay each year for your medical expenses before your insurance company will begin to pay their share.

For example, you have a health plan with a $1,500 deductible. After a stay at an in-network hospital, you might have a medical bill for $30,000. The insurance company is contracted with the hospital and this allows them to receive a substantial discount off the charges that are billed for your services. You would be responsible for paying the first $1,500 out of pocket. At that point, your health plan would begin to pay benefits for the remaining adjusted balance, according to the terms of your policy.

COINSURANCE:

Coinsurance refers to the money that an individual is required to pay for services rendered after your deductible has been paid. Coinsurance is often specified by a percentage.

For example, the insured pays 20% towards the charges for a service, and the insurance company pays 80%. You only owe your portion – in this example 20% – of the adjusted fee that the insurance company determines. After the insured has paid the deductible, he/she is responsible for a percentage of the overall costs, which is specified by the “coinsurance split” (In this example, the coinsurance split was 80/20). Some other common coinsurance splits are 90/10 and 70/30, in which the insured pays the smaller percentage and the carrier pays the higher percentage.

That remains the case until the out-of-pocket maximum for the year is reached. At that point, the insurance company will start to pay 100% of the covered claims, until the end of the year.

OUT OF POCKET MAXIMUM (OOPM):

Your out-of-pocket maximum is a pre-determined limit of money that an individual must pay out of his/her own pocket before the insurance company will pay 100% for the insured’s health care expenses. This pre-determined limit will vary from policy to policy.

 

Join us next week when we discuss a few more insurance terms, specific to transgender surgery!