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Documenting Medical Necessity for Treating Transgender Youth

PIMSY mental health EHR guest blog: documenting medical necessity for transgendered youth

by Beth Rontal, 6.27.16

Solutions for Documenting Medical Necessity + Billing 

Billing for transgender youth can be tricky even though it shouldn't be. I was recently asked how to deal with an insurance company that rejected family therapy for the following case.

The Case

A 13-year-old transgender female came to therapy. Six months previous to starting treatment, she was actively suicidal, cutting and with disordered eating. The therapist has been doing both individual work with the client and family work with the client and her mother.

Therapy was going well enough that the client was no longer suicidal and in fact, now that she has accepted her gender identity, she reported being happier than she’d ever been. Symptoms decreased significantly though she continued to address serious identity issues.

Joint sessions had been very productive, and the therapist felt more were needed, even though the client's presenting symptoms were no longer active.

Insurance Rejection

The problem occurred when the insurance company refused to authorize more family sessions and rejected the appeal. What should she do?

Possible Solutions

1. Since family treatment is a standard of care for transgender youth http://www.hrc.org/resources/world-professional-association-for-transgender-health-wpath, it’s possible to appeal the denial on these grounds, citing research.

2. The client is only six months post suicidal ideation, which puts the client at risk for decompensation.

3. Consider opening a case on the mother and billing through her, diagnosing the mother with an Adjustment Disorder because she is adjusting to her transitioning child. This strategy can buy more sessions and be a faster way of getting treatment approved than waiting for an appeal to come through.

If you continue to bill under the mother, you may eventually need to change her diagnosis to something other than an Adjustment Disorder because some insurance companies don't approve sessions for this diagnosis for more than six months.

4. If you need help writing a letter to justify medical necessity, you can get help here: https://www.insurance.wa.gov/your-insurance/health-insurance/appeal/

What Does the Law Say?

Since these insurance rejections fail to comply with the Affordable Care Act, you might be heartened to know that Elizabeth Warren sponsored a bill in the Senate to ensure patient mental health coverage: https://www.warren.senate.gov/?p=press_release&id=1081 and Joe Kennedy did the same in the House https://kennedy.house.gov/media/press-releases/kennedy-introduces-bill-to-hold-insurers-accountable-for-mental-health-coverage.

If you are at all political, you might want to contact your state representatives and senators to urge them to pass these bills. You can also report any problems to the insurance commissioner of your state.

Take Away

There is no good reason you should struggle to justify medical necessity for a client struggling with transgender issues. Denials violates parity and the standard of care; but you may need to be creative until the insurance companies catch up with the law. 

Ask the Expert

We're giving you an exclusive opportunity to ask Beth your documenting questions. Email your inquiry to This email address is being protected from spambots. You need JavaScript enabled to view it. - and we might feature the answer in an upcoming blog post!

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Beth Rontal, MSW, LICSW, has spent hundreds of hours teaching psychotherapists how to document medical necessity, get authorizations and pass audits by linking effective documentation with good clinical practice.  

An engaging speaker, Beth has presented Misery or Mastery; Documenting Medical Necessity to individuals, groups and clinics and at national conferences. She also serves on the Advisory Board of PIMSY Mental Health EHR. For more information, see Documentation Wizard

 

The views expressed in this article are those of the author and do not necessarily reflect those of PIMSY EHR or its employees.

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