The nondiscrimination in health programs and activities rule went into effect July 18. However (of course there’s a however), health plans have until next year to make some of the changes necessary to comply with the rule.
One area where both providers and plans will need to make changes is to their software systems. These systems will need to handle claims that would normally trigger gender-specific edits.
Here’s how one of those critters works: A doctor submits a claim for a Pap smear for a patient who is listed as male. Somewhere along the line someone’s software is going to flag that as an error and kick it back out with a little note that reads Submit with the correct code plz. That’s fine if the doctor meant to submit a code that is not gender specific or appropriate for a male patient. When the doctor needs to submit a claim for a Trans* patient who is male, the doctor will needs some sort of override. Medicare created such an override in 2009. I see other health plans have adopted it and Health & Human Services suggested the use of the override in the final rule.
However, private plans have time to make that kind of upgrade and an override on the plan’s end won’t help a provider if the practice’s system, or that of an intermediary vendor, keeps saying I’m sorry Dave, and insisting that the provider fix the non-existent problem. (Imagine an email system that won’t let you send an email unless the text of the message is formatted in a specific way. Then imagine that you need to send an email that doesn’t fit the format exactly. Then imagine your income depends on sending lots and lots of emails.)
That’s the type of scenario that a member of a list-serv I frequent was trying to avoid. List member’s practice has a trans* patient and the list member wanted some ideas for entering the patient in the practice’s system in a way that worked for the practice, the patient and his insurer.
Another member made a couple of suggestions which included asking the software vendor to add transgender to the range of gender choices, and to call the insurance company for a pre-authorization when the patient needs a procedure that doesn’t match his listed gender.
(By the way, I’m not paraphrasing to eliminate obnoxious things people said, I’m doing so to keep this thing from devolving into a giant pile of Medadmintechlish. But perhaps it is too late.)
At any rate, in my semi-informed opinion those solutions are fine, because the practice is doing whatever it needs to do to get claims processed and the patient just comes in and receives health care.
If the practice has to wrestle with its software vendor’s rep. in order to get a needed upgrade, that’s not the patient’s concern. If someone has to sit on hold for half a day to get the patient’s pelvic exam cleared, so be it. (However, I would also talk to the payer about installing the Medicare override sooner rather than later.)
My other semi-informed opinion is software upgrades could prove to be the bigger hurdle for practices. Plans have to comply with the law. Software vendors don’t.