April 27, 2012
Dear Dr. Reed,
I have been searching through information on surgeons who perform the GCS/SRS (or whichever acronym you like), and one thing that sticks out is that no surgeons actually accept medical insurance for a procedure that has been labeled medically necessary. As someone with a need for these procedures to be done, I wonder why that is?
As an individual case, I carry Aetna HMO, with full coverage for GCS/SRS, breast augmentation, FFS, among other things (I even got my hair transplant(s) covered fully), and the insurance company does not use “reasonable & customary” with my doctors, due to my medical plan. For example, I am working with Aetna as we speak to have a letter of medical coverage sent out, itemized for the procedures I am schedule for, with the name of the procedure, the procedure code, the cost that the surgeon has quoted me with and with that document, they will craft a document of full coverage for the procedures. This document should serve as a statement, in writing, that the company will pay these fees as shown following the procedures. Shouldn’t this be good enough?
I only ask this because it seems that for many, and myself included, are being excluded from being able to undergo these procedures simply because we cannot raise the necessary tens of thousands of dollars to pay for these procedures upfront. For some, short term loans may be an answer, but at least in my case, a pending
divorce has left my credit score unworthy of a loan for this operation. So here I stand, with great medical insurance in one hand, yet no doctor to go to who will accept it. What have we fought so hard for to get insurance coverage if no one takes it? What point did we have fighting to get it called “medically necessary” if no doctor will perform the procedure without money in their hand upfront?
Perhaps I am missing something.
Thank you for taking the time to address my situation.
Evelyn
April 28, 2012
Good afternoon Evelyn,
There are insurance plans and there are insurance plans.
What they pay out is in good part related to what is paid in,
and if this program is under Johnson and Johnson, this may have
impact. Your experience is atypical, but I am happy it works
for you.
You are welcome to call Aetna and get a confirming letter, if there
is interest in me as your surgeon.. Our fees are posted on web-site.
We do encourage all patients who say they have insurance to
inquire about out of network benefits. If we were to join Aetna we might
find ourselves engaged in taking care of the low end policy holders as well
and that’s what we do not want to do.
Sincerely,
Harold M. Reed, M.D.
305-865-2000
At 08:23 AM 4/28/2012, you wrote:
Dr. Reed,
First, let me say thank you for your response. It is refreshing to hear back from a fellow professional so quickly on such an important topic. Now, on to your response:
If you had taken the time to read my email fully, you would have seen that this is not about how much, or what percent they will pay. This is about Aetna paying for my procedures fully. For example, I recently had 2361 follicular unit transplants done on my head to restore my natural fullness and restore a feminine hairline. At $4.75 per transplant, plus fees, and aftercare, the bill was $11,581. Since the doctor, Philadelphia, PA was not affiliated with any insurance (as hair transplants typically are seen as cosmetic), I added him to my plan as a non-participating provider, giving him the same coverage as my other doctors. Since he was not a network doctor though, he was not contractually obligated to accept the reasonable & customary reimbursement and as such, was paid $11,531. I had the pay a $50 outpatient surgery co-pay.
Again. for example, I am scheduled with Dr. Lyle for forehead advance with brow bone reduction, thyroid cartilage reduction and breast augmentation on August 28th. Because this will be done as an outpatient procedure at a hospital under general anesthesia, there will be hospital fees, anesthesiologist fees and Dr. Lyle’s fees. For all three procedures, Dr. Lyle is billing me $13,600. Aetna has sent me, in writing, that they will pay $13,600 for the procedures. So your worry about money is unfounded.
I hope this answers your questions regarding insurance and calms your fears regarding being paid. I also want to let you know that this insurance program, through Aetna, is self-insured though my company, Johnson & Johnson, where I serve as the Gender Transition Liaison. There are three other MTF TS’s at my company who are currently searching for capable, competent doctors who will work with our insurance. I hope I can go back to them, as well as many others who have insurance, but no where to use it, and let them know that Dr. Harold Reed is one of them.
Sincerely,
Evelyn
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Subject: Re: Insurance
April 27, 2012
Dear Eveleyn,
Simply stated: the reimbursement is not a fair compensation for the tremendous amount of work involved both pre, intra and post-operatively. Transsexual patients need a lot of care and support.
We pay our help very well, have lots of overhead expenses, go to societal meeting occasionally out of the country, at which time our office is not earning any revenue. Insurance companies
typically pay out 1 dollar for every 2 they take in. This covers their cost, and provides for some profit.
Go on line and see what various BC/BS CEO’s in each state earn. Seems to be between 800,000 to 3 million a year.
What does Aetna pay for transsexual vaginoplasty (a 5 hour procedure)?
Also you may be interested to learn 50% of our patients come in with a sponsor. Could be a family member, spouse, significant other, business
partner or church group.
Just think… 50% (plus/minus) of women in America get married and never work another day in their life.
You may wish to approach your insurance carrier about of network provision whereby they will reimburse you for part of the expenses of surgery, if you doctor is not a contracted provide with them.
Thank you for your interest in what we do.
After reading the attached, if you believe I am the doctor
for you, please initiate a consultation over the phone with our office
by sending us your name, address, and telephone number
in an envelope along with a check for 250. We’ll
get started ASAP. We’ll have a lot to talk about.
This year we are re-vitalizing our Grant with a slogan similar
to one a few years ago (“the first 10 in 2010″), now it is
“the first 12 in 2012.” This should reduce your fees
by 10 to 20%, based upon need and availability of funds.
So far 3 positions have been filled this month.
Call the office and speak with Anne our amiable office
manager for details.
Cordially,
Harold M. Reed
1111 Kane Concourse, Suite # 311
Bay Harbor Islands, Florida 33154
305-865-2000