How do I pressure Blue Cross Blue Shield to cover my surgery?

October 27, 2023 5:33 PM

I have gender affirming surgery scheduled for Tuesday in San Francisco, California. I just found out that my insurance, BCBSofVT, has denied my pre-auth on the grounds that it is “not medically necessary”. My surgeon’s office is working with me to put pressure, but BCBS are closed for the weekend. I would like to put some public pressure on them through social and newsmedia, per the recommendation of the insurance liason from my surgeon’s office. How do I best go about this?

Further Details:

- all gender affirming care is deemed medically necessary by the state of VT, so this is an illegal decision of theirs. BCBSofVT is a nonprofit

- I had my first two stages of this surgery at a practice in New England that is now closed due to medical malpractice, so this is my first surgery with this practice. This is my final stage

- this is my first time trying to get gender-related care through BCBS, I have not needed anything from them before now.

- I don’t use social media much (have a fb and instagram, no twitter/X) so my reach is not great, but I can connect with others who may have greater reach

- I have a background in journalism but I kind of doubt that this case will interest journalists much until the date of my surgery is actually passed. That said, I do know how to write and talk to those people

- I am not sure if I want to focus on the transphobic aspect of this case, in case of transphobic public response, but I do feel that this is the most salient part of it. Thought?

- I have all the required letters, medical history, etc, to validate my need for this final stage surgery.

- I have flown across the country and taken a month off of work for this surgery. My financial investment in this particular surgery is significant.

What do you think are some good first steps? How should I proceed? No office that can help me at BCBS is open until Monday morning.

posted by Summers to Law & Government (14 answers total)

You need to confirm that your insurance plan is, in fact, regulated by the state of Vermont. If you bought it on the exchange, it will be. If it's an employer plan, you need to determine whether it's "fully-insured" or "self-insured"--self-insured plans are not regulated by the state (they're technically not insurance plans--the employer sets aside a pot of money to pay claims (self-insures) and pays the insurance company to administer the plan). This may be hard to do on a weekend, but if you can find Vermont-specific boilerplate in the full plan document/certificate of coverage, it's a good bet it's fully-insured and thus regulated by Vermont. (I'm afraid I don't know enough about how Medicaid works to know if you can rely on the state rules for private plans.)

There's the hilariously badly formatted WPATH Statement on Medical Necessity, which is generally the leverage you've got, but it's not worth much.

Also, I am going to me-mail you.
posted by hoyland at 6:28 PM on October 27, 2023 [5 favorites]

You have probably already looked at this, but just in case: this appears to be their Gender Affirming Services policy. Page two covers the requirements for surgery coverage. If you have the evidence to show that you fully qualify, as I assume you do, you will be much better prepared in talking with their office on Monday but also in talking with the press or social media.

I'm sorry this is happening to you; it sounds unbelievably stressful.
posted by praemunire at 7:16 PM on October 27, 2023 [2 favorites]

Are your local (in Vermont) state senator and/or assemblyperson supportive of trans rights? They might be able to bring pressure to bear, and may have staffers working over the weekend whom you can contact directly.
posted by heatherlogan at 7:34 PM on October 27, 2023 [5 favorites]

I would reach out to any trans legal aid/community orgs in both VT and San Francisco about this, and then the general LGBT ones if i didn't get a quick response from the former. Both the explicitly lawyerly ones, and the kind that offer help with documents and name changes etc. A lot of these orgs have That One Person who's just really good at ramming this kind of stuff through, has all the right numbers and emails saved, and often literally knows someone who works at the state insurance board or something along those lines. The reason i say SF too, is if you can find That Person there, there's an ok chance they somehow know That Person at some org in VT, ro someone who moved there, or moved from there but did this there before... etc. It's not a huge community.

It really sucks how often it's true, but a lot of times solving these sorts of last minute fuckups with this specific kind of thing involves just finding the right person who Knows.
posted by emptythought at 7:59 PM on October 27, 2023 [2 favorites]

Honestly I would focus more on "my contract with BCBS, under the regulations of the state of Vermont, says that you will pay for this, and you are now refusing to pay for it in clear violation of our contract" rather than transphobia. Not to say that transphobia isn't in play! But insurance companies deny coverage for all kinds of expensive things besides gender-affirming care.

In addition to the other suggestions above, I would look for news/social media stories about about BCBS of VT denying valid pre-authorizations, whether for gender-affirming care, reproductive care, mental health meds/care, cancer treatments, etc. See if you can put yourself in the larger picture. I have no idea how "social media pressure" works nowadays, unless you already have a large following somewhere or you're close to someone who has one, but if you can find a journalist or online community that's already outraged about BCBS, that's probably a good place to start.

Also I don't know how scheduling works for gender-affirming care but I'm kind of horrified that your surgeon's office let it get to the weekend before your surgery before finding out/telling you that your pre-auth was denied.
posted by mskyle at 5:47 AM on October 28, 2023 [9 favorites]

I’m sorry you are going through this. I don’t have much to offer in terms of weekend resolutions, but if you haven’t already, please also reach out to the office of the health care advocate.
posted by meinvt at 6:02 AM on October 28, 2023 [3 favorites]

I am so sorry! This must be so incredibly frustrating for you.

Insurance denials generally are way up this year. As part of the ACA provisions, states have to have offices for external review of insurance denials.

Here is Vermont’s healthcare external review site. They do have information for emergency appeals as well as a more standard process.

According to the HHS site linked above: “Expedited external reviews are decided as soon as possible – no later than 72 hours, or less, depending on the medical urgency of the case, after the request was received.”

As far as attracting media attention be prepared for a couple of things. First, are you ok with being filmed or photographed and having that information with your name and medical situation on the internet? If this doesn’t sound like an option you want it is less likely that local media will be interested in reporting on your specific case. Approach any media with concise email or written communication about what makes your situation newsworthy, timely, relevant to that outlet’s audience. I think you will have much more success attracting attention to your case if you are able to work directly with an advocacy organization familiar with this issue. If there are LGBTQ+ orgs that are focused on health (for example, are there health centers in Vermont that specifically focus on queer health) they likely have experience helping others effectively with insurance BS.

I have found that Facebook groups are often full of tons of helpful support when dealing with medical bureaucracy if that is an option for you.
posted by forkisbetter at 8:23 AM on October 28, 2023 [1 favorite]

"Closed on the weekend" sounds wrong to me-- for emergency/expedited appeals, usually there is a way to get through, because people do go to the hospital on the weekend. There should be a number, possibly try calling through the nurse line.

Just as a note, some employer plans are not regulated by the state of Vermont, as hoyland pointed out-- these might be called self-funded, self-insured, or "ERISA" plans. These plans have fewer review processes and less external oversight, but not none. You do not need to figure this out before you call the emergency external appeal line linked above (which is what I would do in this situation, right now). The state'll tell you if you're not eligible for their review process, so you don't lose anything by trying. Similarly, generally, you must exhaust the internal process before you go to external review, but there is an exception for emergency situations, so again, you don't lose a lot by trying both at once. At worse they'll deny expedition and you'll be in the same place as you were.

What's the cost of the surgery if you go ahead while fighting the denial? Will the surgeon perform it while you're fighting it out? Can you launch a gofundme to cover the catastrophic possibility and publicize it through e.g. the LGBT Center here, TGIJP, Transgender Law Center...?
posted by peppercorn at 11:11 AM on October 28, 2023 [2 favorites]

Response by poster: Thanks for your advice everyone! I ended up sending an email to the entire BlueCross/BlueShield of VT leadership board, saying that their decision was illegal, and threatening to go to the press on Monday. I got a direct call from someone on the board this afternoon saying “there was a misunderstanding” and my surgery has been approved. So, another win for Vermonters :)
posted by Summers at 5:29 PM on October 28, 2023 [49 favorites]

> I got a direct call from someone on the board

Make sure to thank that person profusely for their help! That may help the next person to come along with a similar problem.

Good luck with your surgery!
posted by flug at 7:55 PM on October 28, 2023 [2 favorites]

I'm really glad you pulled this one out of the bag. The buildup of micro-traumas stemming from insurance uncertainty, unexpected denials, and billing problems with GCS is an underdiscussed subject. Don't be surprised if significant emotions about this event emerge during your recovery, or months down the line. Especially given your history of being served by a clinic shut down for malpractice...like, even if the malpractice didn't affect your procedures, simply knowing it occurred can be very upsetting. There is really no relevant support available, in my experience, in part because these surgeries are still not widespread in the trans community. Even trans-knowledgeable therapists tend to be pretty clueless. It doesn't help that there is kind of this attitude that you should just be super grateful the surgery did take place, what are you complaining about. (And to that end, it is certainly never a trauma I'd bring up with other trans people who desire surgery but cannot access it at all.)

Basically, you might want to have a plan for self care in place.

I would also say your surgeon's office deserves feedback about how this affected you on both a practical and emotional level. It is bizarre--downright irresponsible, in fact--for a GCS office to have submitted paperwork so late that an insurance decision would be emerging only four days before a vagino-, phallo-, metioidoplasty, etc. I mean, I am wtf-ing over here.

Congrats on what I hope is your final stage of surgery!
posted by desert outpost at 2:35 AM on October 29, 2023 [5 favorites]

Oh and also, I hope you never have to deal with a retrospective denial, but if you ever do, at least you can prepare in advance, as opposed to learning what it is when you get a bill for $120,000 months after having your pre-authorized surgery.

If this ever does happen, two bits of advice: 1. do anything you can to get your doctor's office and insurance company on a three-way conference call with you, though be aware that sometimes state-specific insurance companies will refuse to do this with out-of-state doctors for some ungodly fucking reason, and 2. call the customer service line and ask for a nurse case manager, because even if dealing with this isn't exactly their job, they possess actual human empathy, and also tend to be able to call around and pull strings that you as a regular person cannot.
posted by desert outpost at 2:44 AM on October 29, 2023 [3 favorites]

As someone who works in insurance authorizations for a hospital, I'm of the view the patient shouldn't have to be involved in this process at all. The office should have handled it fully. I hope this practice is less negligent than the other one that closed.
posted by greatalleycat at 10:20 AM on October 30, 2023 [1 favorite]

It is bizarre--downright irresponsible, in fact--for a GCS office to have submitted paperwork so late that an insurance decision would be emerging only four days before a vagino-, phallo-, metioidoplasty, etc. I mean, I am wtf-ing over here.

My top surgery prior auth came through last minute, having been set in motion a good three months prior. The insurance company dithered, then went back to the surgeon asking for documentation they'd already been sent, then dithered some more. Yes, they were required to respond faster than they did. I lost the planned OR slot, but fortunately it only slipped by like four hours.
posted by hoyland at 6:25 PM on October 30, 2023