I have both primary insurance (through my university) and secondary insurance (Medicaid). My surgeon accepts both, and Medicaid has never been an issue before. I was supposed to have gender-affirming surgery a few months ago, but my primary insurance denied it, saying it wasn’t medically necessary.
I called Medicaid multiple times, and they told me they would cover the surgery as long as a prior authorization and the primary denial letter were submitted. They also said that NYS Medicaid doesn’t do medical necessity reviews for surgical revisions like this.
I asked the hospital billing department to submit the prior authorization, but they refused. They said Medicaid would deny it because my primary already did. Medicaid told me this wasn’t true and even offered to explain it directly to the biller, but she refused to speak to them.
I’ve consulted other surgeons who said they wouldn’t have a problem submitting the prior authorization. I’m ready to transfer care, but I’m frustrated that I have to switch doctors just because the billing department won’t listen. Is there a way to file a complaint about this? It’s exhausting to deal with, and now I have to wait months for a surgery that should’ve already happened.
Usually, if primary denies for medical necessity, Medicaid won’t cover it either. But since your primary denied it for lack of coverage, Medicaid should review the prior auth. The staff might be misunderstanding the process.
@Amory
Yeah, I think the confusion is around medical necessity. Medicaid told me surgical revisions for gender-affirming procedures can’t be denied for that reason. They pointed me to NYS Medicaid rules that say revisions aren’t subject to medical necessity reviews if the original surgery was deemed necessary.
The surgeon might accept Medicaid, but the hospital may not want to deal with it. Hospitals expect higher reimbursement from commercial insurance. Medicaid pays way less, and they might not want to take that loss.
@Smart
This. Your surgeon is only part of the equation. The hospital, anesthesiologist, and staff all have to agree. Some won’t do elective surgeries with just Medicaid because the reimbursement is too low. Any chance you can pay out of pocket?
Honestly, I’d transfer care. It sounds like they’re not going to change their mind. They might be afraid Medicaid will deny it too, leaving them unable to bill you at all.
Cale said:
Honestly, I’d transfer care. It sounds like they’re not going to change their mind. They might be afraid Medicaid will deny it too, leaving them unable to bill you at all.
Yeah, it’s probably not personal. They just don’t want to risk getting stuck doing a surgery for free.
Medicaid can be a hassle. You should check if the hospital is asking for more documentation than usual. Sometimes they need psych evaluations, hormone therapy records, and letters from doctors. A nurse case manager from Medicaid could help guide you through the process.
If I were the biller, I’d probably be cautious too. Call center reps can say whatever, but it’s not binding. Even prior authorizations aren’t a guarantee of payment, so they might be trying to avoid doing unpaid work.
Honestly, this is why many providers don’t take Medicaid. The pay is low, and the process is frustrating. I’d transfer care or ask to speak to someone higher up at the hospital.