4. The doctor said very encouraging. However, this has been a persuasive strategy in some cases. Copyright TransHealthCare.org & Trans Media Network, 2011-2022. James S, Herman J, Rankin S, et al. insurance appeals for pediatric reconstructive surgery: a micro cost analysis and how-to guide. Woolhandler S, Campbell T, Himmelstein DU. https://links.lww.com/PRSGO/B647.). Especially with the establishment of multi-disciplinary gender health teams across the United States, coordination of care through a consistent group of trained administrative staff knowledgeable in the process and appeals process for gender health procedures would potentially reduce the burden on individual offices and surgeons. This could be a good time to join (or form!) Quality of life of individuals with and without facial feminization surgery or gender reassignment surgery. Also referred to as Facial Gender Confirmation Surgery (FGCS), these procedures are becoming more and more popular, and increasingly are covered by insurance. From an historical perspective, both private health insurance carriers and government insurance have declined claims for FFS. The major difference between approval (Group B) versus denial (Group C) was that the former primarily consisted of plans insured by California and, thus, under the jurisdiction of California law, whereas Group C plans were entirely self-insured employer (ERISA) plans, which are exempt from state regulation. LGBT legal service projects? Do you have access to out-of-network providers or in-network only. Received for publication February 2, 2021; accepted February 27, 2021. Once you've identified a surgeon who takes your insurance, ask them to submit a preauthorization. Patients who receive prior authorization are still required to pay for the cost of their facial feminization surgery in advance. (See table 2, Supplemental Digital Content 2, which displays the total time and cost of the insurance approval process per group. The addition of multi-level appeals in Groups B and C increased the total time for a definitive decision (7.0 and 5.1 months, respectively) and required both surgeon and administrative time to navigate the process (10.8 and 12.0 hours, respectively). It's an attempt to make the face as attractive as possible for as long as it lasts. These patients underwent a standard approval process no different from other reconstructive procedures (Group A). The FFS Surgeons listed below are highly qualified plastic, cosmetic and maxillofacial Surgeons who regularly perform FFS. Such multi-level appeals begin with a surgeon-initiated appeal, which is then also denied. If they have referenced expert guidelines or current research in devising your care plan, they should state that and provide citations. In the Group A patients, FFS under Medi-Cal still requires preauthorization, just like private insurances. Transgender women may choose FFS as part of their male-to-female transition process. Post-surgery garments; Medical tests and x-rays; When choosing a board-certified plastic surgeon for facial feminization surgery, remember that the surgeon's experience and your comfort with him or her are just as important as the final cost of the surgery. 2018; 319:691697. As much as possible, Dr. Salgado will do what he can to keep costs at a minimum. Surgeries are performed by our world experts in facial reconstructive surgery, including: Drs. 2010; 19:10191024. Dr. Thomas Satterwhite Dr. Crane is one of only a few surgeons in the world who is trained as both a plastic surgeon and urologist and has also completed fellowships in reconstructive urology and gender reassignment surgery. Administrative time, including obtaining initial authorizations, appeals, IMRs, and additional phone calls, averaged to 7.2 1.0 hours spent per patient. Call Your Insurance Company to Ask if Gender Affirming Surgery is a Covered Benefit. Plast Reconstr Surg. Submission and review of initial authorization request (1 month); 2. Historically, FFS hasn't been covered by health insurance or government healthcare. Only if your insurance provider authorizes a Letter of Agreement. For example, a number of state-mandated denial overturns in Group B patients resulted in billing challenges postsurgery. The surgeons listed below are highly qualified plastic, reconstructive, craniofacial, maxillofacial and cosmetic surgeons who offer gender-affirming facial surgery. 2016; 137:438448. Though specifics required by insurance vary (and might be laid out explicitly in your Certificate of Coverage) I recommend every person have three letters of support. Dr. Mangubat specializes in Top Surgery, Breast Augmentation and Body Sculpting, Gender Confirming Facial Surgery and Hair Grafting. Support groups? However, this is starting to change. Yet, a number of studies have demonstrated that FFS is not only associated with improvement in quality of life for transfeminine patients, but also, for some patients, the most important aspect of transition.47 Although significant barriers exist, an improvement in insurance coverage for FFS has occurred over time, albeit navigation of the process is both laborious and confusing. This is also the point at which general 201 level guidance ceases to be useful. Patients were stratified into 3 groups based on authorization process: Group A (standard approval, n = 26, 65.0%) including public and private insurances; Group B (extended approval, n = 10, 25.0%) consisting of private insurance plans that initially denied and required multi-level appeals for denial overturn; and Group C (denial, n = 4, 10.0%), including private insurance plans that denied even after multi-level appeals. Dr. Facque joined the Gender Confirmation Centers team in September 2020 as a full-time Associate Surgeon specializing in Facial Gender Confirmation Surgery, Top Surgery and Body Contouring. Look here for licensed dentists practicing in the state. Error bars denote standard error. Data is temporarily unavailable. During Your FFS Procedure How long it takes: This depends on what you are having done. Every state is different so start with Google and reach out to these services in your state, theyre here for you! A Systematic Review of Tranexamic Acid in Plastic Surgery: Whats New? Ask them how many FFS surgeries they perform within a year. In practice for more than 20 years, Dr. Salgado performs all aspects of transgender surgeries, from Facial Feminization and Top Surgery, to complex genital procedures such as Vaginoplasty and Phalloplasty. 11. We recommend you take at least two weeks off from work to recover, but expect up to six to eight weeks of decreased activity. These investigators reported patient satisfaction following facial feminization surgery, including outcome measurements after forehead slippage and chin re-modeling. For example, some may be reluctant to perform an osteotomy of the anterior table of the frontal bone for setback in an outpatient surgery center and, thus, default to a less aggressive method of frontal bone recontouring, which may be an undercorrection for certain patients. The report of the 2015 U.S. transgender survey. 3. ), You will also need to factor in the costs of airfare, transportation, and accommodation if youre not from the San Francisco Bay Area. This operation is most commonly performed in transgender women or non-binary people as a type of gender-affirming surgery. To filter results, enter information and 'click search icon' and/or select from the dropdown lists. *, Time and cost of the insurance approval process for FFS. There are 301 level topics not covered here- going out of network to an office who will only give you CPT codes performed, getting a network exception to go to a provider with skills not available among in-network surgeons, etc. Lastly, a third subgroup of patients (Group C), all with private insurance, were denied for surgery despite multi-level appeals, peer-to-peer discussions, and IMR. He subsequently completed a Gender Surgery Fellowship with Dr. Toby Meltzer and Dr. Ellie Zara Ley. Group A averaged 1.1 months for approval, requiring 1.4 hours of administrative time translating to $38.18 per patient. Costs of health care administration in the United States and Canada. Insurance coverage for FFS is an important issue for a number of reasons for both patients and surgeons. One patient may have severe dysphoria over their forehead, while one may have dysphoria over their upper lip. Health insurance is unnecessarily difficult when it comes to gender affirming surgery. San Francisco, CA 94108. Dr. Harris is a highly skilled, board-certified Surgeon in the Dallas area who has been developing an international reputation for transgender surgery. Temporal trends in gender-affirming surgery among transgender patients in the United States. In Patient X's case, she has achieved the full extent of facial feminization that can be expected with hormone therapy. Total Staff: 34. This should be sent to you in written form, with the specific reason for the denial included. Group B (extended approval) primarily encompassed all patients who were initially denied but, after undergoing a multi-level appeal process, was ultimately approved. Which, though I knew FFS is expensive, is a bigger estimate than I've ever seen for the procedure. Most trans women elect to have all facial feminization procedures performed at once, or in two phases (upper face and lower face). Ainsworth TA, Spiegel JH. For people without local connections, the facebook group, " FFS Facial Feminization Surgery / Transgender TG TS " and the FFS Forums on susans.org are good places to seek community support as well. During his plastic surgery residency, Dr. Esmonde worked in the Transgender Health Program at OHSU. Rhinoplasty. JAMA. Submission and review of IMR (1 month). In total, 4 patients (10.0%) were ultimately denied despite multi-level appeals and IMR requests. Insurances are constantly changing and we cannot make any guarantees concerning insurance coverage or approval. First, one of the most significant barriers to FFS for patients is the ability to pay for surgery, which ranges from $40,000 upwards for full-face, one-stage surgery. Facial Feminization Surgery (FFS) is becoming more and more popular, but it can be hard to narrow down the surgeons who best perform these complex surgeries. I always advise people to try with the insurance they have before they switch to another plan. See all insurance information. Upon receipt of a deposit for your surgery, our practice may offer to submit a prior authorization request to your insurance provider. We are often asked by our patients about the cost offacial feminizationand if their health insurance will cover them for thevariety of proceduresincluded in their surgery. The objective is to soften the facial . 3). 2003; 349:768775. It involves plastic surgery techniques in which the jaw, chin, cheeks, forehead, nose, and areas surrounding the eyes, ears or lips are changed to create a more feminine appearance. Thus, specifying any one procedure as medically necessary while excluding other facial procedures reflects a lack of understanding of the nature of the diagnosis. Next, you want an awareness of any explicit inclusions or exclusions for transgender care in your "Certificate of Coverage," the document that lays out what is covered in what circumstances. Complete New Patient Questionnaire. In these circumstances, both complications and revisions are covered as reconstructive procedures, whereas self-pay patients may be responsible for secondary surgical costs. These procedures may include: Tummy tuck, called abdominoplasty. Dr. Keith is a board-certified and fellowship-trained Plastic Surgeon with expertise in Gender Affirmation Surgery. Which, though I knew FFS is expensive, is a bigger estimate than I've ever seen for the procedure. Dr. Charles Shih. Our surgeons specialize in a variety of facial feminization procedures, such as forehead reduction, jaw contouring, and chin surgery. Gray R, Nguyen K, Lee JC, et al. Though WPATH has released the new SOC, it will take insurance companies time to evolve. Leigh JP, Tancredi D, Jerant A, et al. Among the total cohort, most patients had private insurance (n = 23, 57.5%), followed by Medi-Cal (n = 13, 32.5%), and Medicare (n = 4, 10.0%). These IMRs are often requested through the California Department of Managed Healthcare resulting in state-mandated overturn of the insurance decision, or less commonly, through the insurance company for ERISA or self-insured plans which do not fall under state jurisdiction. An estimated 10 patients (25.0%), all with private insurance, underwent an extended approval process requiring multi-level appeals and denial overturn after IMR and frequently, state intervention. Forehead (frontal bone recontouring, recontouring of superior orbital rim, hairline lowering). Dr. Mangubats excellent surgical skills, experience and dedication to transgender health have made him the most sought after surgeon for transgender surgery in the Pacific Northwest. ENQUIRE NOW. Facial Feminization Surgery: A Guide for the Transgendered Woman. On average, the authorization process required approximately 1 month to complete and cost on average $38 worth of time to coordinate administratively. 3). 6. Facial Feminization Surgery (FFS) is a group of facial procedures that alter the face to create more classically feminine characteristics, such as a higher brow, a more refined feminine nose, and less pronounced Adams apple. Gender-Affirming Surgery: Original Article. Dr. Satterwhite is a board-certified Plastic and Craniofacial Surgeon in San Francisco who is dedicated to offering the highest level of surgical care to the transgender community. Dr. Ley has joined Dr. Scott Mossers Gender Confirmation Center in San Francisco, where she will begin seeing patients in March 2022. Dr. Youssef is a top Cosmetic Surgeon in the greater Los Angeles area and Director of the Transgender Surgery Institute of Southern California. In addition to legislative changes, the rationale for increasing coverage may be related to calculations on the cost-effectiveness of coverage. Insurance authorization process for FFS.The insurance authorization process for FFS begins with submission of two letters of support from a mental health provider and primary care physician following surgical consult. We believe that for many transgender women, FFS is medically necessary to treat gender dysphoria. See the list at the end of this article for surgeons who will accept some form of insurance benefits directly.What makes someone a FGCS surgeon anyway? The generalizability of the findings presented here is limited by state laws. All patients with public insurance (Medi-Cal or Medicare) as well as a small subset of private insurance plans were approved after initial submission of authorization request or did not require approval before surgery (Medicare) (Fig. As gender dysphoria is highly individual, such procedures will vary by anatomical areas associated with dysphoria for each individual patient as well as decision-making from the treating surgeon. You need an understanding of your insurance benefits in general: What would any covered surgery cost you? We're gonna try really hard to get my insurance to cover it, but I'm not holding my breath. From the cohort, 3 subgroups were delineated. Also referred to as Facial Gender Confirmation Surgery (FGCS), these procedures are becoming more and more popular, and increasingly are covered by insurance. Initially, you would need to be seen in the office for an examination/consultation to determine the scope of yoursurgeryto determine the exact cost of your facial feminization. In addition to following WPATHs SOC format, it is helpful if it is specifically tailored to FGCS. Unlike Group B, patients within Group C only had plans that were self-insured under ERISA. In total, attempting and succeeding at obtaining insurance coverage for FFS is a significant time and cost burden that may be difficult to overcome for a number of plastic surgical practices, suggesting ramifications for patient accessibility. The multi-level appeal process included physician-initiated appeal, patient-initiated appeal, and independent medical review (IMR). This means that the surgeon is either already in network with your insurance and is willing to send a prior authorization, or has an office willing to do the legwork of doing a letter of agreement with your insurance. Second, while complications are not high in FFS, they may occur. These letters, in addition to following the WPATH standards of care, are the place to communicate the severity of the dysphoria- does your dysphoria impede activities of daily living, for instance by making you unable to leave for work on time? The administrator hourly compensation set at our institution was used for the cost analysis. https://links.lww.com/PRSGO/B648.). Specific surgical procedures were requested based on patient desires and clinical assessment, with the goal of completing FFS in a one-stage surgery. Dr. KathleynBrandstetter. Are there transgender advocacy groups? Group A is similar to other medically necessary reconstructive procedures where authorization is requested and procedures are authorized. In general, patients who undergo FFS will stay overnight after their procedure and return home the following day. The work cannot be changed in any way or used commercially without permission from the journal. This study highlighted the successes and burdens associated with obtaining insurance authorization for FFS. . Plastic surgery on the face. One potential consideration for reducing time and costs is to centralize administrative staff for gender health insurance authorizations. Patients who are definitively denied (Group C) may then exit their employer-based plan and switch to a plan under California jurisdiction on the health insurance exchange. (See table 1, Supplemental Digital Content 1, which displays requested CPT codes and associated terminology for facial feminization surgery. Once CGSP receives your form, you will be referred to Plastic Surgery for a consultation. Read on to find out why you might pay more or less, and whether the cost is really worth it. Wolters Kluwer Health, Inc. All rights reserved. Mallory C, Tentindo W. Medicaid coverage for gender-affirming care. Wolters Kluwer Health In addition to administrative time, multi-level appeals required time from the attending craniofacial surgeon for peer-to-peer reviews, writing appeal letters, and patient counseling over the 6-month period, in total averaging 3.6 0.5 hours per patient. (See table 2, Supplemental Digital Content 2, which displays the total time and cost of the insurance approval process per group. If the insurer refuses those attempts, you can appeal externally, but that will almost certainly require professional legal support. This procedure can alter both soft tissues as well as the facial bone to achieve more feminine-looking facial features. For self-pay patients, cost will frequently dictate the operative and postoperative setting such that patients may be preferentially or solely performed in an outpatient setting. Schedule surgery Gender-affirmation surgery gives transgender people a physical appearance that aligns with their gender. First, one of the most significant barriers to FFS for patients is the ability to pay for surgery, which ranges from $40,000 upwards for full-face, one-stage surgery. Subsequently, the process typically follows one of three paths: Group A (standard approval), Group B (extended approval), and Group C (denial). Secondly, the current study does not take into account the postsurgical administrative and billing time consumption and costs. Fortunately, as insurance coverage for gender confirmation surgeries has increased, so has physician interest in training. Please read a few important elements consider when booking. It is of great importance to note that there is no one-size-fits-all solution for facial gender affirmation with respect to determining medical necessity of procedures. A total of 36 patients (90.0%) have been approved by insurance. Finally, Group C (denial) included private insurance plans under ERISA that resulted in denial despite multi-level appeals and IMR requested from the plan. He currently performs approximately 200 genital reconstruction surgery cases per year in Scottsdale, Arizona and Portland, Oregon. Ultimately this letter is between you and your provider, but here is some sample language that has been helpful to patients I've worked with: "Patient X has been adherent to two years of hormone replacement therapy including (specific estrogen regimen.) You need to come in for an in-person consultation AND pay a deposit to secure your surgery datebeforewe will submit for prior authorization. However, some insurers are beginning to cover FFS from select surgeons. Additionally, the patients who exited their employer-based plans to buy health insurance on the exchange paid more for health insurance by foregoing employer contributions. Dr. Hadeed is a board-certified surgeon who specializes in Transgender Surgery, including chest/breast procedures, facial surgeries and body sculpting for both trans men and women. Dr. Sajan places the highest priority on providing his transgender patients with excellent surgical care and natural-looking results. Plastic and Reconstructive Surgery Global Open9(5):e3572, May 2021. Start with ensuring that you have an in-depth understanding of your insurance benefits. These procedures are also called Facial Feminization Surgery or FFS, but in agreement with the experts, I've shifted to using FGCS. Unlike California plans, self-insured plans are not under the CA DMHC and, thus, the final outcome is more variable. Error bars denote standard error. Prior to meeting with the social worker, patients should complete this assessment document. $8995. The Group C authorization process, which resulted in denial of services, consumed a 9-fold higher amount of time (P < 0.001) and 26-fold higher cost (P < 0.001) when compared with Group A (Fig. 8. Some error has occurred while processing your request. Facial feminization surgery: the forehead. The standard premium for Medicare Part B in 2020 is $144.60 each month, and there is a $198 annual deductible cost. Days, a 50-year-old Berkeley resident, had just returned from a month-long trip to Spain in February, where she underwent a procedure known as facial feminization surgery, or FFS. Patients seeking services from our practice are personally and fully responsible for payment of all fees and costs related to your FFS surgery and medical care. Although your FFS may not be covered by your insurance company its definitely worth doing the research. Care Credit approval amounts can vary from person to person. A total of 40 transfeminine patients were identified (mean age 35.6 2.2 years) (Table 1). This denial should also lay out your options for appeal- both internal (basically, asking the insurance company to reconsider) and external. Her surgery was performed by a craniofacial surgical team called the FACIALTEAM. Simplifying facial feminization surgery using virtual modeling on the female skull. Dr. Dulin is a board-certified surgeon with many years of experience performing Top Surgery, Metoidioplasty, Breast Augmentation, FFS and Orchiectomy. Dr. Dorafshar is a highly distinguished plastic and reconstructive surgeon who specializes in gender-affirming facial surgery. Two letters from mental health providers. Do you have out of network benefits, or are you limited to providers in the network? As stated above, all patients within this group were covered by private insurance plans that were not within the purview of the State of California and, thus, were not eligible for state intervention. They will need letters of support from you for the preauthorization, following WPATHs Standards Of Care. What's your out of pocket max? In contrast to Group A, patients who required significant efforts in the form of multi-level appeals, peer-to-peer reviews, and IMRs were designated Groups B and C, depending on ultimate approval versus denial as the outcomes, respectively. These surgeries can reduce the size and shape of the forehead, alter and refine the nose, make the lips fuller and . 1. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. William Hoffman, MD and Jason Pomerantz, MD from the UCSF Division of Plastic Surgery, and Drs. We will commonly prescribe you with medications for common post-surgical side effects such as pain, nausea, and constipation. It can be just as important or even more important than sex reassignment surgery (SRS) in reducing gender dysphoria and helping trans women integrate socially as women. Facial feminisation surgery can involve a combination of all or some of the below cosmetic procedures. We performed a cost analysis of the pre-surgical insurance process for patients seeking FFS.

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