Janet Morris, our Insurance Expert, has worked tirelessly for nearly 10 years to get GRS covered and approved by major insurance companies. She has fought to get decent reimbursement, and has had to battle for pre-authorization before surgery, and for payment afterwards.
Despite trying to work with Medicare, we unfortunately have been unsuccessful. They have repeatedly denied our claims as not covered, not medically necessary, etc. That has led us to terminate our contracts with Medicare. We believe that patients and activists need to take up the fight and force Medicare to stand up to their word and cover these surgeries, contracting specifically with surgeons.
We are not contracted with most state Medicaid plans, although do have some agreements in place with certain Medi-Cal plans, and we are contracted with Washington Medicaid. (Washington Medicaid patients, please review the following carefully: http://www.hca.wa.gov/assets/billers-and-providers/Physician-related-services-20160701.pdf – Specifically pages 284-291. In addition to our forms and requirements below, please provide all that WA Medicaid requires to help us insure success with your pre-authorization). We will try to work with each Medi-Cal plan on a case by case basis. This is a long process, and often a struggle, but if you can manage the leg work, we may be able to help. Contact our office for further information.
More and more insurance companies are covering GRS (in fact, more than half of our patients have insurance that covers transgender surgery), and after many years, the process is becoming a easier. To our knowledge, we are one of the few GRS surgical practices who not only accepts insurance, but will pre-authorize your procedure. This means that if your insurance company covers GRS, you will only have to pay your coinsurance up front. We will do the leg work, and help you through this often daunting process. We are in network with most major insurance companies, and those that we are not in network with will often work with us, including Aetna, as there are so few surgeons who perform this procedure. We are experts regarding getting GRS covered by insurance… let us help!
Before we start a pre-authorization for you, please check the Specific Exclusions section of your insurance plan and see if Transgender Surgery, Genital Reassignment Surgery, etc., is listed as an exclusion. If it is excluded, you’ll need to approach your employer and ask them to add the coverage to your insurance plan. We can provide letters of medical necessity which can be of help in nudging an employer to add transgender surgery to their current health plan.
If you don’t see that Transgender Surgery is specifically excluded or if you are unsure, we are happy to do an insurance authorization. Pre-authorization can take 3-4 months to initiate due to the volume of requests we receive, so please give us plenty of time, and keep in mind your insurance renewal date, and our surgery backlog. Also, keep in mind that we tend to have quite a long waiting list for surgery (currently over a year for outpatient and FTM procedures, and approaching 3 years for the MTF GRS). We do keep a cancellation list for patients who wish to get in sooner.
You can help us be successful in seeking pre-authorization by following the guidelines below:
- Send in your Surgery Application and $1000 deposit. (The deposit is generally non refundable. However, if we are unable to pre-authorize your insurance after exhausting all options, and you are unable to pay out of pocket or secure new insurance, we will refund.) The $1000 will go toward your deductible. If your insurance pays at 100% you will be reimbursed. You should not send in the deposit if you have a WA Medicaid or Medi-Cal plan.
- Send in the completed Insurance Pre-authorization Request Form and GRS Disclosure Form
- Send Enlarged and legible copies of the front and back of your insurance id card
- Your letters of recommendation from two qualified therapists. Your insurance company will most likely require two letters of recommendation, both from therapists, and one from a doctorate level therapist. We continue to pressure insurance companies to change their requirements to adhere to the Version 7 SOC, but in the meantime, in order to get your surgery approved, two letters, both from therapists, are required.
Once we receive all of the above in our office, we can put you in line for pre-authorization. Again, give us 3-4 months. You will receive word from us when we hear from your insurance company, and they should send you a decision in writing as well.